Multidrug-Resistant Bloodstream Infections in Internal Medicine: Results from a Single-Center Study.

OBJECTIVES: Infections due to multidrug-resistant organisms (MDROs) are expanding globally and are associated with higher mortality rates and hospital-related costs. The objectives of this study were to analyze the trends of MDRO bacteremia and antimicrobial resistance rates in Internal Medicine wards of our hospital and to identify the variables associated with these infections. METHODS: During a 6-year period (July 1, 2011-June 30, 2017), patients with positive blood culture isolates hospitalized in the Internal Medicine wards in the Santa Croce and Carle Hospital in Cuneo, Italy, were assessed. We performed an analysis taking into consideration the time trends and frequencies of MDRO infections, as well as a case-control study to identify clinical-demographic variables associated with MDRO bacteremias. RESULTS: During the study period a total of 596 blood cultures were performed in 577 patients. The most frequently identified organism was Escherichia coli (33.7%), followed by Staphylococcus aureus (15.6%) and S epidermidis (7.4%). The percentage of resistance to methicillin among S aureus isolates showed a decreasing trend, whereas rates of extended-spectrum ß-lactamase-producing Enterobacteriaceae and carbapenemase-producing Klebsiella pneumoniae increased during the study period. Multivariate analysis showed that the nosocomial origin of the infection, hospitalization during the previous 3 months, residence in long-term care facilities, presence of a device, antibiotic exposure during the previous 3 months, and cerebrovascular disease were independently associated with bacteremia by resistant microorganisms. CONCLUSIONS: Our analysis reveals a concerning microbiological situation in an Internal Medicine setting, in line with other national and regional data. The risk variables for infection by MDRO identified in our study correspond to those reported in the literature, although studies focused on Internal Medicine settings appear to be limited.

Long-term recurrence of venous thromboembolism after short-term treatment of symptomatic isolated distal deep vein thrombosis: A cohort study.

Isolated distal deep vein thrombosis (IDDVT) is a common clinical manifestation of venous thromboembolism (VTE). However, there are only scant and heterogeneous data available on the long-term risk of recurrent VTE after IDDVT, and the optimal therapeutic management remains uncertain. We carried out a retrospective cohort study of consecutive patients diagnosed with symptomatic IDDVT between 2004 and 2011, according to a predefined short-term treatment protocol (low molecular weight heparin (LMWH) for 4-6 weeks). The primary outcome was the occurrence of recurrent VTE. A total of 321 patients were enrolled. IDDVT was associated with a transient risk factor or cancer in 165 (51.4%) and 56 (17.4%) patients, respectively. LMWH was administered for 4-6 weeks to 280 patients (87.2%), who were included in the primary analysis. Overall, during a mean follow-up of 42.3 months, 42 patients (15%) developed recurrent VTE, which occurred as proximal DVT or PE in 21 cases. The recurrence rate of VTE per 100 patient-years was 3.5 in patients with transient risk factors, 7.2 in patients with unprovoked IDDVT, and 5.9 in patients with cancer ( p=0.018). At multivariable analysis, unprovoked IDDVT and previous VTE were significantly associated with recurrent VTE (HR 2.16, 95% CI 1.12-4.16 and HR 1.97, 95% CI 1.01-3.86, respectively). In conclusion, the long-term risk of recurrent VTE after IDDVT treated for 4-6 weeks is not negligible, in particular in patients with unprovoked IDDVT or cancer. Further studies are needed to clarify whether a longer, but definite treatment duration effectively prevents these recurrences.

Hepatic brucelloma.

We present a case of hepatic abscess caused by Brucella melitensis (or hepatic brucelloma) diagnosed in a 59-year-old man 33 years after an episode of acute brucellosis that had completely resolved. Recovery from symptoms and a decrease in lesion size seen on radiological assessment were achieved through prolonged combined antibiotic therapy, without the need for surgery. Hepatic brucelloma is a rare complication of brucellosis, which is the most common zoonosis globally, mainly occurring in specific endemic areas and causing a range of clinical manifestations. In this Grand Round, we review the clinical manifestations, diagnostic approach (through laboratory, radiology, and histology findings), differential diagnosis, treatment, and prognosis of hepatic brucelloma.

Venous lower-limb evaluation in patients with acute pulmonary embolism.

OBJECTIVES: Compressive ultrasonography (CUS) of the lower limbs is the first choice for identifying deep venous thrombosis (DVT) in patients with symptomatic pulmonary embolism (PE). The aim of this study was to uncover clinical characteristics and CUS findings in patients with proven PE and their correlations with PE extent. METHODS: A total of 524 consecutive cases of proven symptomatic PE diagnosed between January 1996 and December 2006 were reviewed. RESULTS: Mean age was 71.06 ± 14.43 SD years; 244 patients (46.6%) were men. DVT signs or symptoms were present in 30.9% of patients and were associated with the femoral site (P = 0.029). CUS was performed in 383 patients (73.1%) and DVT was found in 75.5%. In 94.1% of patients DVT was proximal (popliteal and/or femoral), which would have been then identified by simplified CUS. CUS was performed significantly more often in presence of signs or symptoms of DVT (P < 0.001), less often in presence of medical illnesses (P = 0.040), age ≥75 years (P = 0.001) and death in hospital (P < 0.001). Signs or symptoms of DVT were predictors of positive CUS (P < 0.001), presence of medical illnesses (P = 0.020), central venous catheter (P = 0.035), death in hospital (P = 0.032) were predictors of negative CUS findings. Neither clinical findings nor CUS were associated with PE extent. CONCLUSIONS: In patients with proven symptomatic PE, signs or symptoms of DVT are present only in 1/3 of cases and are significantly more frequent when DVT is extended to the femoral vein. Simplified CUS of the lower limbs has a high sensitivity in finding proximal DVT. CUS is not able to predict PE extent.

Primary hepatic carcinoid: a case report and literature review.

Carcinoids are tumors derived from neuroendocrine cells and often produce functional peptide hormones. Approximately 54.5% arise in the gastrointestinal tract and frequently metastasize to the liver. Primary hepatic carcinoid tumors (PHCT) are extremely rare; only 95 cases have been reported. A 65-year-old man came to our attention due to occasional ultrasound findings in absence of clinical manifestations. His previous medical history, since 2003, included an echotomography of the dishomogeneous parenchymal area but no focal lesions. A computed tomography scan performed in 2005 showed an enhanced pseudonodular-like lesion of about 2 cm. Cholangio-magnetic resonance imaging identified the lesion as a possible cholangiocarcinoma. No positive findings were obtained with positron emission tomography. Histology suggested a secondary localization in the liver caused by a low-grade malignant neuroendocrine tumor. Immunohistochemistry was positive for anti chromogranin antibodies, Ki67 antibodies and synaptophysin. Octreoscan scintigraphy indicated intense activity in the lesion. Endoscopic investigations were performed to exclude the presence of extrahepatic neoplasms. Diagnosis of PHCT was established. The patient underwent left hepatectomy, followed by hormone therapy with sandostatine LAR. Two months after surgery he had a lymph nodal relapse along the celiac trunk and caudate lobe, which was histologically confirmed. The postoperative clinical course was uneventful, with a negative follow-up for hematochemical, clinical and radiological investigations at 18 mo post-surgery. Diagnosis of PHCT is based principally on the histopathological confirmation of a carcinoid tumor and the exclusion of a non-hepatic primary tumor. Surgical resection is the recommended primary treatment for PHCT. Recurrence rate and survival rate in patients treated with resection were 18% and 74%, respectively.