Pseudomonas aeruginosa Infections Are Associated with Infection Recurrence in Arteriovenous Grafts Treated with Revision.

Background and Objectives: This study was conducted to investigate whether Pseudomonas aeruginosa (PA) infections of arteriovenous grafts (AVGs) recur more frequently than other bacterial infections following treatment with revision. Materials and Methods: Operative procedures, including total excision, subtotal excision, and revision, were performed on 60 patients to treat 65 AVG infections. Final outcomes were classified as no infection recurrence, infection recurrence, and death without prior recurrence. In the competing risk setting, the cumulative incidence was estimated using the cumulative incidence function and Gray's test, and the associations between outcomes and different variables were estimated using a subdistribution hazard (SDH) model. Results: Comparing AVG infections with and without recurrence, PA infection was not associated with a higher risk of infection recurrence (p = 0.13); however, the first operative procedure type was associated with infection recurrence (p = 0.04). AVGs with PA infection were associated with a higher total number of surgical interventions (p < 0.05) than AVGs without PA infection. Regarding the cumulative incidences of outcomes, for AVGs treated with subtotal excision or revision, the cumulative incidence of recurrent infection was 3.3-fold higher for those with PA infection than without one year after the first surgery. However, when AVGs were treated with revision alone, the cumulative incidence was 4.1-fold. After excluding AVGs treated with total excision, the SDH model was applied, obtaining a hazard ratio for infection recurrence of 16.05 (p = 0.02) for AVGs with PA infection compared with AVGs without PA infection. No other variables were significantly associated with infection recurrence. Conclusions: For subtotal resection and revision, AVGs infected with PA had a higher recurrence rate than those infected with other species. However, revision surgery may aggravate the recurrence rate.

Assessment of Antimicrobial Activity of Dehydrated Amniotic Membrane in Infectious Keratitis: A Small Retrospective Case Series and In Vitro Study.

PURPOSE: To describe a small case series of infectious keratitis with poor visual outcomes after amniotic membrane (AM) placement and to prospectively evaluate whether AM demonstrates antibacterial activity in vitro against pathogens commonly isolated from infectious corneal ulcers. METHODS: A retrospective case series and in vitro study of antibacterial activity of dehydrated AM using disk diffusion and measurement of inhibitory zones for bacterial assessment and inverted microscopy analysis for Acanthamoeba sp. growth. RESULTS: Three cases of known etiology infectious keratitis are described where the clinical presentation worsened after treatment with AM. In vitro analysis of dehydrated AM, with and without a soft contact lens, demonstrated no inhibition of growth against Pseudomonas aeruginosa or Streptococcus pneumoniae. There was minimal growth inhibition of Staphylococcus aureus, although these zones of inhibition were much smaller than that surrounding the positive control. For Acanthamoeba sp., solubilized, dehydrated AM did not alter cyst density. CONCLUSIONS: In an in vitro analysis, dehydrated AM did not provide evidence for a potentially clinically meaningful antibacterial effect against organisms commonly isolated from corneal ulcers.

The impact of infectious diseases consultation on the management and outcomes of Pseudomonas aeruginosa bacteraemia in adults: a retrospective cohort study.

BACKGROUND: Pseudomonas aeruginosa bacteraemia (PAB) is associated with high mortality. The benefits of infectious diseases consultation (IDC) has been demonstrated in Staphylococcal aureus bacteraemia and other complex infections. Impact of IDC in PAB is unclear. This study aimed to evaluate the impact of IDC on the management and outcomes in patients with PAB. METHODS: This is a retrospective cohort single-centre study from 1 November 2006 to 29 May 2019, in all adult patients admitted with first episode of PAB. Data collected included demographics, clinical management and outcomes for PAB and whether IDC occurred. In addition, 29 Pseudomonas aeruginosa (PA) stored isolates were available for Illumina whole genome sequencing to investigate if pathogen factors contributed to the mortality. RESULTS: A total of 128 cases of PAB were identified, 71% received IDC. Patients who received IDC were less likely to receive inappropriate duration of antibiotic therapy (4.4%; vs 67.6%; p < 0.01), more likely to be de-escalated to oral antibiotic in a timely manner (87.9% vs 40.5%; p < 0.01), undergo removal of infected catheter (27.5% vs 13.5%; p = 0.049) and undergo surgical intervention (20.9% vs 5.4%, p = 0.023) for source control. The overall 30-day all-cause mortality rate was 24.2% and was significantly higher in the no IDC group in both unadjusted (56.8% vs 11.0%, odds ratio [OR] = 10.63, p < 0.001) and adjusted analysis (adjusted OR = 7.84; 95% confidence interval, 2.95-20.86). The genotypic analysis did not reveal any PA genetic features associated with increased mortality between IDC versus no IDC groups. CONCLUSION: Patients who received IDC for PAB had lower 30-day mortality, better source control and management was more compliant with guidelines. Further prospective studies are necessary to determine if these results can be validated in other settings.

Combination of aztreonam, ceftazidime-avibactam and amikacin in the treatment of VIM-1 Pseudomonas aeruginosa ST235 osteomyelitis.

We describe a challenging case of patient with metallo-beta-lactamase-producing Pseudomonas aeruginosa sternal osteomyelitis following aortic valve replacement with biological prosthesis. The strain exhibited a multidrug-resistance phenotype carrying the blaVIM-1 gene and belonged to the high-risk clone sequence type ST235. The patient was successfully treated with surgical debridement plus antibiotic therapy with ceftazidime/avibactam, aztreonam, and amikacin. Time-kill curves showed that this triple antibiotic combination at 1 × MIC was strongly synergic after 8 h, achieving 99.9% killing and maintaining this until 48 h.

Aortoduodenal Fistula After Endovascular Aortic Repair for an Inflammatory Abdominal Aortic Aneurysm: A Case Report.

Aortoenteric fistula after endovascular aortic repair for an abdominal aortic aneurysm is a rare but severe complication. Particularly, a case of inflammatory abdominal aortic aneurysm is extremely rare and there are only 3 reported cases. A 70-year-old man underwent endovascular aortic repair for impending rupture of an inflammatory abdominal aortic aneurysm and was medicated steroids for approximately 2 years. Four years after endovascular aortic repair, he developed endograft infection with an aortoduodenal fistula and a left psoas abscess. He underwent total endograft excision, debridement, in situ reconstruction of the aorta using prosthetic grafts with omental coverage, and digestive tract reconstruction to prevent leakage. Pseudomonas aeruginosa was detected in the infected aortic sac. The patient has not experienced recurrence of infection in the 35 months since his operation.

Chronic Suppurative Otitis Media: A Case Report.

BACKGROUND CONTEXT: Chronic Suppurative Otitis Media (CSOM) is a common cause of hearing impairment and disability. CSOM caused by Pseudomonas aeruginosa is usually treated with topical ciprofloxacin and resistance to ciprofloxacin in CSOM isolates has rarely been reported. CASE PRESENTATION: A 24-year-old male patient with CSOM due to p. aeruginosa was reported. CSOM was prolonged for ten years and physician prescribed topical ciprofloxacin drops, pus suctioning and ear pH alteration. The treatment wasn't effective and the patient came back to the clinic with relapse of suppurative otitis media. P. aeruginosa was isolated as the cause of CSOM and the isolate was resistant to ciprofloxacin, aztreonam, imipenem, gentamicin, doripenem, cefepime, levofloxacin, amikacin and susceptible to colistin and ceftazidime. There were two mutations in gyrA and eight mutations were observed in nfxB genes. Finally, tympanomastoidectomy was done. CONCLUSION: Usually topical antibiotics, especially ciprofloxacin, is effective against ear infections but our case was different and the P. aeruginosa isolated from CSOM was resistant to most of the antibiotics. One reason for CSOM recurrence might be surgery failure. The routine and primary treatment for CSOM did not seem sufficient and tympanomastoidectomy is suggested to be the best treatment approach for these patients.

Pseudomonas aeruginosa nosocomial meningitis in neurosurgical patients with intraventricular catheters: Therapeutic approach and review of the literature / Meningitis nosocomial por Pseudomonas aeruginosa en pacientes portadores de catéteres intraventriculares: aproximación terapéutica y revisión de la literatura

BACKGROUND: Pseudomonas aeruginosa neurosurgical meningitis is a rare entity, usually related with intraventricular catheters and associated with high mortality rates. We describe the clinical characteristics, treatment and outcomes of a series of neurosurgical meningitis caused by P. aeruginosa along 1990-2016. METHODS: Descriptive, retrospective study of all postsurgical meningitis due to P. aeruginosa related to intraventricular catheters in Hospital Universitario Central de Asturias, between 1990 and 2016. Clinical features, therapeutic approaches and prognostic factors were analyzed statistically. A binary logistic regression analysis was performed to determine the factors influencing the infection mortality. RESULT: 51 episodes from 51 different patients with CSF culture positive for P. aeruginosa were reviewed. Seventeen patients (33.3%) died as a direct consequence of the infection. Univariate analysis showed that mortality was higher in the group of patients treated with ceftazidime (12 vs. 15, p = 0.068, OR 3.040 [0.877-10.544]) and lower in patients whom had received intrathecal therapy (2 vs. 13, p = 0.050, OR 4.64 [0.80-34.93]), without differences observed between those patients treated with aminoglycosides or with colistin. Any patient treated with colistin died (0 vs. 6, p = 0.067, OR: not defined). In the multivariate analysis mortality was only significant higher for patients without catheter withdrawal (p = 0.014) and lower for those patients who received intrathecal therapy (p = 0.05) or adequate empirical treatment (p = 0.006). CONCLUSIONS: The mortality of P. aeruginosa meningitis is high especially in infections without catheter withdrawal and in patients for whom the intrathecal route of administration was not used. Catheter withdrawal was an independent factor of good outcome in our series

ANTECEDENTES: La meningitis nosocomial por Pseudomonas aeruginosa es una entidad poco frecuente, generalmente relacionada con catéteres intraventriculares y asociada con altas tasas de mortalidad. Se describen las características clínicas, con especial hincapié en su tratamiento, de una serie de meningitis neuroquirúrgicas por P. aeruginosa entre 1990 y 2016. MÉTODOS: Estudio descriptivo, retrospectivo, de todas las meningitis posquirúrgicas por P. aeruginosa relacionadas con catéteres intraventriculares en el Hospital Universitario Central de Asturias entre 1990 y 2016, con especial hincapié en los enfoques terapéuticos y factores pronósticos. Los factores asociados con mortalidad se analizaron mediante regresión logística binaria. RESULTADOS: Se revisaron 51 episodios de 51 pacientes diferentes con cultivos de LCR positivos para P. aeruginosa. Diecisiete pacientes (33,3%) murieron como consecuencia directa de la infección. La mortalidad fue mayor en el grupo de pacientes tratados con ceftazidima (12 vs. 15, p = 0,068, OR 3,040 [0,877-10,544]) y menor en los pacientes que habían recibido terapia intratecal (2 vs. 13, p = 0,050, OR 4,64 [0,80-34,93]), sin diferencias en estos últimos entre los tratados con aminoglucósidos o con colistina. Ningún paciente tratado con colistina falleció (0 vs. 6, p = 0,067, OR no definida). El análisis multivariable únicamente confirmó la asociación con la ausencia de terapia intratecal (p = 0,05) o tratamiento empírico adecuado (p = 0,006). CONCLUSIONES: La mortalidad de la meningitis por P. aeruginosa es elevada, especialmente en pacientes en quienes no se utilizó la vía de administración intratecal. La retirada del catéter fue un factor independiente de buena evolución en nuestra serie

Pyogenic Spondylodiscitis of the Thoracic Spine: Outcome of 1-Stage Posterior Versus 2-Stage Posterior and Anterior Spinal Reconstruction in Adults.

OBJECTIVE: The aim of this study was to compare the clinical, radiologic, and functional outcomes of a 1-stage posterior treatment versus a 2-stage posterior-anterior treatment in patients with pyogenic thoracic spondylodiscitis. METHODS: A 1-stage posterior debridement, stabilization, and fusion with titanium-coated polyetheretherketone (PEEK) or mesh cage through a dorsolateral approach was performed in group A. A 2-stage procedure with initial posterior stabilization and debridement and second-stage fusion with a PEEK cage or mesh cage was performed with an anterior approach in group B. Clinical outcomes included Oswestry Low Back Pain Disability Questionnaire and visual analog scale score. Radiologic outcomes included fusion rate and kyphotic angle correction. Secondary variables included pathogens, complications, blood loss, and operative time. RESULTS: One-level spondylodiscitis was treated surgically in the thoracic spine of 47 patients: 25 patients in group A and 22 patients in group B. The most frequent segment was T12-L1 (27%). There was a significantly longer operative time and greater blood loss (P > 0.001) in group B. At last follow-up, sagittal profile reconstruction was significantly better (P > 0.05) in group B. Both groups showed similar radiologic results with fusion in 92% of cases. Improved clinical outcomes, pain, and quality of life were achieved in both groups with no significant differences between the 2 groups. CONCLUSIONS: Better reconstruction of the sagittal profile was achieved in the posterior-anterior-treated group, but this did not affect the clinical outcome. No significant differences were found in the clinical and functional outcomes between the 2 groups. Posterior-anterior combined treatment should be considered in cases of large anterior defects if a posterior reconstruction is inadequate.

Pseudomonas aeruginosa-induced bilateral endophthalmitis after bilateral simultaneous cataract surgery: case report / Endoftalmite bilateral induzida por Pseudomonas aeruginosa após cirurgia bilateral simultânea de catarata: relato de caso

ABSTRACT Bilateral simultaneous cataract surgery (BSCS) has gained popularity among eye surgeons in many countries. This study examines the case of a 77-year-old patient who developed bilateral Pseudomonas aeruginosa endophthalmitis following bilateral simultaneous cataract surgery. Immediate bilateral vitrectomy and intravitreal antibiotics injection were performed. Ultimately, both eyes were eviscerated due to pain refractory to treatment and no light perception.

RESUMO A cirurgia bilateral simultânea de catarata ganhou popularidade entre cirurgiões oftalmológicos em muitos países. Este estudo examina o caso de um paciente de 77 anos que desenvolveu endoftalmite bilateral por Pseudomonas aeruginosa após uma cirurgia bilateral simultânea de catarata. Vitrectomia bilateral imediata e injeção de antibióticos intravítreos foram realizadas. Em última análise, ambos os olhos foram eviscerados devido à dor refratária ao tratamento e sem percepção de luz.

Pseudomonas aeruginosa-induced bilateral endophthalmitis after bilateral simultaneous cataract surgery: case report.

Bilateral simultaneous cataract surgery (BSCS) has gained popularity among eye surgeons in many countries. This study examines the case of a 77-year-old patient who developed bilateral Pseudomonas aeruginosa endophthalmitis following bilateral simultaneous cataract surgery. Immediate bilateral vitrectomy and intravitreal antibiotics injection were performed. Ultimately, both eyes were eviscerated due to pain refractory to treatment and no light perception.

Tracheostomy in children: Epidemiology and clinical outcomes.

BACKGROUND: Tracheotomy is performed in children for a variety of indications, but can place them at increased risk of lower airway infection with pathogenic organisms. While prior studies have identified Pseudomonas aeruginosa and Staphylococcus aureus as the most common lower airway pathogens in children with tracheostomies, little is known about the clinical implications of chronic growth of pathogens. METHODS: The North Carolina Children's Airway Center database was utilized to identify all pediatric patients with tracheostomy from 2007 to 2012; these data were cross-referenced to a microbiology database of all tracheostomy cultures. Data on hospitalizations, intensive care unit admissions, and length-of-stay were abstracted from the medical record and analyzed using multivariate methods. RESULTS: We identified 185 children with tracheostomy, of whom chronic bacterial growth status could be defined in 69. P aeruginosa was a common pathogen isolated from tracheostomy cultures, with 49% (91/185) of patients growing this organism at least once. P aeruginosa combined with other gram-negative rods were isolated in 63% (116/185) of subjects at least once. Those who chronically grew gram-negative rods had significantly more hospitalizations, longer total lengths-of-stay, and longer intensive care unit lengths-of-stay than those who did not. These differences remained significant when data were normalized to account for number of available cultures. CONCLUSION: These data suggest that clinical outcomes may be worse in children with tracheostomies who chronically grow gram-negative rods. Our findings may help guide clinicians in managing children with tracheostomies, though further studies are needed to establish best practice guidelines in these patients.

Effectiveness of a monofilament wound debridement pad at removing biofilm and slough: ex vivo and clinical performance.

OBJECTIVE: Removal of slough and other devitalised tissue is an important step in biofilm-based wound care (BBWC) and wound bed preparation. Debridement is key to management of both slough and biofilm, and a number of methods are available to achieve this, including surgical/sharp and mechanical debridement. Developments have led to products indicated for debridement of wounds, including a sterile pad consisting of monofilament fibres. Our aim is to examine the effectiveness of a monofilament wound debridement pad (WDP), Debrisoft. METHOD: We assessed the WDP, in laboratory tests, for the removal of mature biofilm from porcine dermal tissue in an ex vivo model, and the clinical management of sloughy wounds that would benefit from debridement. We used the UPPER score to determine the superficial infection status. RESULTS: The WDP was effective in removing biofilm from porcine dermal tissue. A case series of 10 patients with chronic wounds suggested that the WDP was beneficial in the removal of slough. All chronic wounds had slough and were cleaned weekly, for four weeks, using the MDP to achieve improved healing and a clean wound bed. The average wound size decreased from 8.09cm2 at baseline to 2.3cm2 at week four, with three wounds healed completely. Exudate was reduced, and the UPPER score improved in every patient. CONCLUSION: These results indicate that the WDP effectively debrides biofilm and slough, and contributes to care that follows the principles of wound bed preparation and BBWC.

Severely infected pneumoceles of the frontal sinus in patients with mental retardation and brain atrophy treated by endoscopic sinus surgery.

We herein present three cases of abnormally expanded frontal sinuses (pneumoceles) with severe infection in patients with mental retardation and brain atrophy. Two patients previously underwent laryngotracheal separation surgery, and bacteriological examinations of purulent nasal discharge revealed infections caused by drug-resistant bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii. As conservative medical treatments were ineffective, all three patients were treated by computed tomography-guided endoscopic sinus surgery. This navigation system is useful for safer surgery in the area of anatomic deformity. The clinical findings, possible etiologies and surgical treatment of these cases are discussed.

Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience.

BACKGROUND: Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem. METHODS: Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients. RESULTS: A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: "conservative management," "excision of mesh with primary closure," "single-stage reconstruction," "immediate staged repair," and "repair in contaminated field." Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional ("secondary") repairs after recurrence, 75% were eventually able to achieve "hernia-free" state. CONCLUSIONS: This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.

Long-Term Success With Driveline Exit Site Relocation for Deep Driveline Infection in Left Ventricular Assist Device Patients.

OBJECTIVE: Driveline infection is a common complication of durable left ventricular assist device support. The majority involve the driveline exit site and can be treated with antibiotics and local wound care. Less frequently, these infections extend into deeper tissues and surgical debridement is necessary. Few studies have described the surgical strategy for treatment of deep driveline infection or have reported long-term outcomes. With a growing population of patients being implanted as destination therapy, there is an obvious need to evaluate and optimize treatment for complex driveline infections. METHODS: Outcomes of patients undergoing durable left ventricular assist device implantation at a single center between 2011 and 2017 were reviewed retrospectively. Data including occurrence of driveline infection, pathogen, time to driveline infection, and treatment strategy were abstracted from the electronic medical record. RESULTS: Driveline infection occurred in 10 (16.4%) of 61 patients at a median of 362 days (Q1 = 99, Q3 = 694) after primary left ventricular assist device implantation. Three (30.0%) of 10 driveline infections were categorized as deep and did not resolve with intravenous antibiotic therapy. In these cases, a multistage approach that included initial debridement and exteriorization of the infected driveline, followed by delayed surgical relocation of the driveline in a clean vascularized soft tissue bed, was used. Long-term device salvage was achieved in all cases. CONCLUSIONS: An aggressive surgical strategy, including debridement and formal relocation of the driveline exit site, can result in long-term device salvage after deep driveline infection. This approach is a less invasive alternative to device exchange for refractory driveline infections.

[Severe bilateral pseudomonas sclerokeratitis in comatose patient (clinical case)]. / Razvitoi dvustoronnii sinegnoinyi sklerokeratit u patsientki v kome (klinicheskii sluchai).

The article presents a clinical case of severe bilateral pseudomonas sclerokeratitis in a patient with occlusion hydrocephalus and intracranial hypertension, who was in a coma and on a ventilator for 20 days. At first examination (7 days after the onset of purulent keratitis, during which the process had been rapidly progressing), the clinical picture included lagophthalmos, severe purulent corneal ulcer, bilateral purulent scleromalacia, perforated cornea in the left eye. On the same day, in order to maintain eye integrity, urgent reconstructive penetrating sclerokeratoplasty with subsequent sclerocorneal coating was performed in both eyes right in the intensive care unit. Parts of the melted iris and ciliary body pars plana that were left in place were abundantly washed with BSS and moxifloxacin solutions - 150 µg/ml. Postoperative care included forced instillations of antibiotics and antiseptics. Two years after the first surgery, 2 more full-thickness corneal transplantations were performed in the patient's right eye aiming at restoration of its optical system. Thus, immediate sclerokeratoplasty with anterior segment irrigation and intraocular administration of highly diluted antibiotics appeared to be the only chance to save the vision in one eye. The fellow eye, where perforation occurred as a result of severe purulent sclerokeratitis and purulent iridocyclitis, despite all measures taken, lost its sight. After three surgeries (penetrating sclerokeratoplasty and two re-PK), visual acuity in the only seeing (right) eye was 0.1, which can be considered a satisfactory result.