Absceso hepático piógeno: presentación clínica y predictores de evolución desfavorable / Pyogenic liver abscess: clinical presentation and predictors of unfavorable outcome

Objetivos Describir clínicamente el absceso hepático piógeno (AHP) e identificar factores asociados a evolución desfavorable. Material y métodos Revisión retrospectiva de historias de pacientes con absceso hepático (1996-2009), incluyendo los que cumplían criterios diagnósticos de AHP. Se clasificaron en evolución favorable y desfavorable (sepsis grave, complicaciones infecciosas a distancia, complicación local, ingreso en cuidados intensivos, ingreso > 30 días, fallecimiento, reingreso).Resultados Se incluyen 54 AHP, 65% hombres, edad media 61 años. Factores predisponentes: enfermedad biliopancreática, 33%; ingreso reciente, 20%; enolismo, 15%; diabetes mellitus, 15%; antecedente de neoplasia digestiva, 11%, y de cirugía abdominal, 11%. Origen: criptogénico, 65%; biliar, 31%; portal, 4%. Sintomatología: fiebre, 100%; dolor abdominal, 65%; vómitos, 37%; hepatomegalia, 33%; síndrome de respuesta inflamatoria sistémica, 26%; ictericia, 9%. Hemocultivos positivos, 40%, y cultivo de pus, 65%. Escherichia coli y Streptococcus spp. fueron los aislamientos más frecuentes. Se efectuó drenaje percutáneo en el 72% (el 6% también quirúrgico), y recibieron solo antibioterapia el 28%. Evolución desfavorable 52%, asociada a mayor edad (p=0,016), antecedentes de enfermedad biliopancreática (p=0,007), síndrome de respuesta inflamatoria sistémica al diagnóstico (p=0,005), alteración de la coagulación (p=0,043), elevación de AST (p=0,033) y etiología biliar (p<0,001). Conclusiones El AHP se desarrolla en pacientes con comorbilidad, si bien más frecuentemente son criptogénicos. La mayoría curan con antibioterapia y drenaje percutáneo, sin cirugía. La mortalidad es del 9%, pero la mitad sigue una evolución desfavorable, que se asocia a la etiología biliar y a determinadas alteraciones analíticas (AU)

Objectives To describe the clinical features of pyogenic liver abscesses (PLA) and identify the factors associated with an unfavorable outcome. Material and methods We performed a retrospective review of the clinical histories of patients with liver abscess (1996-2009), including those that met the diagnostic criteria for PLA. Outcome was classified as favorable or unfavorable (severe sepsis, distant infectious complications, local complications, intensive care unit admission, admission for>30 days, death, readmission).Results There were 54 patients with PLA (65% men), with a mean age of 61 years. Predisposing factors consisted of biliopancreatic disease in 33%, recent admission in 20%, alcoholism in 15%, diabetes mellitus in 15%, a history of gastrointestinal neoplasm in 11% and abdominal surgery in 11%. The cause was cryptogenic in 65%, biliary in 31%, and portal in 4%. Symptoms consisted of fever in 100%, abdominal pain in 65%, vomiting in 37%, enlarged liver in 33%, systemic inflammatory response syndrome in 26%, and jaundice in 9%. Blood and pus cultures were positive in 40% and 65%, respectively. The most frequently isolated microorganisms were E. coli and Streptococcus spp. Percutaneous drainage was performed in 72% (surgical drainage was also performed in 6%), and antibiotic treatment alone was administered in 28%. Outcome was unfavorable in 52% and was associated with greater age (p=0.016), a history of biliopancreatic disease (p=0.007), systemic inflammatory response syndrome at diagnosis (p=0.005), coagulation alterations (p=0.043), aspartate aminotransferase elevation (p=0.033), and biliary etiology (p<0.001).Conclusions PLA developed in patients with comorbidity, although most were cryptogenic. The majority of PLA were resolved with antibiotic therapy and percutaneous drainage, without surgery. Mortality was 9%, but half the patients had unfavorable outcome, associated with biliary etiology and some laboratory alterations (AU)

[Pyogenic liver abscess: clinical presentation and predictors of unfavorable outcome]. / Absceso hepático piógeno: presentación clínica y predictores de evolución desfavorable.

OBJECTIVES: To describe the clinical features of pyogenic liver abscesses (PLA) and identify the factors associated with an unfavorable outcome. MATERIAL AND METHODS: We performed a retrospective review of the clinical histories of patients with liver abscess (1996-2009), including those that met the diagnostic criteria for PLA. Outcome was classified as favorable or unfavorable (severe sepsis, distant infectious complications, local complications, intensive care unit admission, admission for>30 days, death, readmission). RESULTS: There were 54 patients with PLA (65% men), with a mean age of 61 years. Predisposing factors consisted of biliopancreatic disease in 33%, recent admission in 20%, alcoholism in 15%, diabetes mellitus in 15%, a history of gastrointestinal neoplasm in 11% and abdominal surgery in 11%. The cause was cryptogenic in 65%, biliary in 31%, and portal in 4%. Symptoms consisted of fever in 100%, abdominal pain in 65%, vomiting in 37%, enlarged liver in 33%, systemic inflammatory response syndrome in 26%, and jaundice in 9%. Blood and pus cultures were positive in 40% and 65%, respectively. The most frequently isolated microorganisms were E. coli and Streptococcus spp. Percutaneous drainage was performed in 72% (surgical drainage was also performed in 6%), and antibiotic treatment alone was administered in 28%. Outcome was unfavorable in 52% and was associated with greater age (p=0.016), a history of biliopancreatic disease (p=0.007), systemic inflammatory response syndrome at diagnosis (p=0.005), coagulation alterations (p=0.043), aspartate aminotransferase elevation (p=0.033), and biliary etiology (p<0.001). CONCLUSIONS: PLA developed in patients with comorbidity, although most were cryptogenic. The majority of PLA were resolved with antibiotic therapy and percutaneous drainage, without surgery. Mortality was 9%, but half the patients had unfavorable outcome, associated with biliary etiology and some laboratory alterations.

Meningitis bacteriana por bacilos gramnegativos en adultos inmunodeprimidos no neuroquirúrgicos. Réplica / Bacterial meningitis due to gram-negative bacilli in immunosuppressed adults who have not undergone neurosurgery. Reply

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[Bacterial meningitis due to gram-negative bacilli in adults]. / Meningitis bacteriana por bacilos gramnegativos en adultos.

INTRODUCTION: Gram-negative bacilli are causative agents of bacterial meningitis in the neonatal period but rarely cause meningitis in adults without risk factors. AIM: To report on meningitis due to gram-negative bacilli (MGNB) in adults diagnosed in a hospital over a 25-year period. PATIENTS AND METHODS: We reviewed the medical records of all patients with an age > or = 14 years who had been diagnosed with MGNB between 1982 and 2006. RESULTS: Fifteen cases of MGNB are included (10.5% of the cases of bacterial meningitis with an identified aetiology), with a mean age of 48 years (14-79). Twelve (80%) were post-operative: recent neurosurgery (9 cases, 75%) and having a neurosurgical device (8 cases, 67%) were risk factors. Three (20%) were spontaneous: two were of a urinary origin and one had an undetermined origin. The aetiology was: Pseudomonas aeruginosa (3 cases), Escherichia coli (3 cases), Enterobacter aerogenes (2 cases), Pseudomonas fluorescens (1 case), Klebsiella pneumoniae (1 case), Morganella morganii (1 case), Acinetobacter anitratus (1 case), Acinetobacter iwoffii (1 case) and Flavobacterium brevis (1 case); in one patient with Gram positive staining for gram-negative bacilli, the culture was negative, and three of them (20%) were mixed infections (Staphylococcus spp.). Three patients (20%) died. CONCLUSIONS: In adults, gram-negative bacilli rarely cause spontaneous meningitis, but are a common causation of post-neurosurgical meningitis and in those with neurosurgical devices. The mortality rate of MGNB is high.

Meningitis bacteriana por bacilos gramnegativos en adultos / Bacterial meningitis due to gram-negative bacilli in adults

Introducción. Los bacilos gramnegativos son agentes etiológicos de meningitis bacteriana en el período neonatal pero raramente causan meningitis en adultos sin factores de riesgo. Objetivo. Describir las meningitis por bacilos gramnegativos en adultos, diagnosticadas en un hospital durante un período de 25 años. Pacientes y métodos. Se revisaron las historias clínicas de los pacientes con edad >= 14 años que habían sido diagnosticados de meningitis por bacilos gramnegativos entre 1982 y 2006. Resultados. Se incluyen 15 casos de meningitis por bacilos gramnegativos (10,5% de las meningitis bacterianas de etiología identificada), con una mediana de edad de 48 años (intervalo: 14-79 años). Doce (80%) fueron postoperatorias:neurocirugía reciente (9 casos, 75%) y ser portador de un dispositivo neuroquirúrgico (8 casos, 67%) fueron los factores de riesgo. Tres (20%) fueron espontáneas: dos de origen urinario y una de origen no determinado. La etiología fue: Pseudomonas aeruginosa (3 casos), Escherichia coli (3 casos), Enterobacter aerogenes (2 casos), Pseudomonas fluorescens (1 caso), Klebsiella pneumoniae (1 caso), Morganella morganii (1 caso), Acinetobacter anitratus (1 caso), Acinetobacter iwoffii (1 caso) y Flavobacterium brevis (1 caso); en un enfermo con tinción de Gram positiva para bacilos gramnegativos el cultivo resultó negativo, y tres (20%) fueron infecciones mixtas (Staphylococcus spp.). Tres pacientes (20%) fallecieron. Conclusiones. En adultos, los bacilos gramnegativos raramente causan meningitis espontánea, pero son una etiología frecuente de meningitis posneuroquirúrgicas y en portadores de dispositivos neuroquirúrgicos. La mortalidad de la meningitis por bacilos gramnegativos es elevada (AU)

Introduction Gram-negative bacilli are causative agents of bacterial meningitis in the neonatal period but rarely cause meningitis in adults without risk factors. Aim. To report on meningitis due to gram-negative bacilli (MGNB) in adults diagnosed in a hospital over a 25-year period. Patients and methods. We reviewed the medical records of all patients with an age >= 14 years who had been diagnosed with MGNB between 1982 and 2006. Results. Fifteen cases of MGNB are included (10.5% of the cases of bacterial meningitis with an identified aetiology), with a mean age of 48 years (14-79). Twelve (80%) were post-operative: recent neurosurgery (9 cases, 75%) and having a neurosurgical device (8 cases, 67%) were risk factors. Three (20%) were spontaneous: two were of a urinary origin and one had an undetermined origin. The aetiology was: Pseudomonas aeruginosa (3 cases), Escherichia coli (3 cases), Enterobacter aerogenes (2 cases), Pseudomonas fluorescens (1 case), Klebsiella pneumoniae (1 case), Morganella morganii (1 case), Acinetobacter anitratus (1 case), Acinetobacter iwoffii (1 case) and Flavobacterium brevis (1 case); in one patient with Gram positive staining for gram-negative bacilli, the culture was negative, and three of them (20%) were mixed infections (Staphylococcus spp.). Three patients (20%) died. Conclusions. In adults, gram-negative bacilli rarely cause spontaneous meningitis, but are a common causation of postneurosurgical meningitis and in those with neurosurgical devices. The mortality rate of MGNB is high (AU)