Three years' experience of dialysis event surveillance.

BACKGROUND: The main study aim was to track infections, evaluate performance, and identify opportunities for improved practice since infections, especially those associated with multidrug-resistant organisms, are the second most common cause of death among end-stage renal disease patients. METHODS: This study describes the establishment of baseline dialysis event surveillance at a large dialysis center. Every month, the dialysis center staff reported the total number of maintenance hemodialysis patients to the department of infection control and hospital epidemiology. The surveillance system for dialysis events included monthly monitoring of hemodialysis patients in outpatient settings for positive blood cultures, intravenous antimicrobial initiation, and local vascular access infections. RESULTS: We calculated the pooled mean rates of positive blood cultures, intravenous antimicrobial initiation, and local vascular access infections during the period from June 1, 2014 to September 30, 2017. Results indicated more dialysis events were attributed to the CVC than any other dialysis vascular access. Regardless of vascular access type, intravenous antimicrobial initiation was the most commonly reported dialysis-associated event. CONCLUSIONS: Dialysis events surveillance can be used to produce a decrease in both morbidity and mortality rates in hemodialysis patients.

Primary and secondary arterial fistulas during chronic Q fever.

OBJECTIVE: After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever. METHODS: In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis. RESULTS: Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%). CONCLUSIONS: The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not.

Peritonitis as presentation of aorto-caval fistula with Salmonella choleraesuis-associated abdominal aortic aneurysm.

BACKGROUND: The majority of aorto-caval fistulae occur spontaneously, either as a result of rupture of an existing atherosclerotic abdominal aortic aneurysm into the vena cava or secondary to iatrogenic injuries during peripheral angiography or surgery. Aorto-caval fistula from an infected aortic aneurysm is a rare scenario, but potentially lethal. METHODS: Case report and review of the literature. CASE REPORT: A 63-year-old female with diabetes mellitus and liver cirrhosis was admitted for intractable abdominal pain with rebound tenderness. A computed tomography scan demonstrated an abdominal aortic aneurysm and ill-defined peri-aortic fluid with air density and evidence of a fistula between the aorta and the inferior vena cava. Salmonella cholerasuis had been isolated from a blood culture at a previous admission. Urgent endovascular exclusion of the aorto-caval fistula was carried out, and the infra-renal abdominal aneurysm was repaired using a Cook Zenith TX2 aortic stent graft. She received parenteral ceftriaxone for four weeks. CONCLUSIONS: This case shows acceptable short-term results after endovascular repair of a Salmonella-infected aorto-caval fistula.

Persistent endoleak after endovascular aneurysm repair for acute Q-fever-infected aortocaval fistula.

We present a case of an endovascular aneurysm repair for a Q-fever-infected acute abdominal aortic aneurysm with aortocaval fistula. Type 2 endoleak persisted after successful endovascular repair.

Gastric variceal bleeding precipitated by a mycotic splenic arteriovenous fistula in a cirrhotic patient: radiological diagnosis and endovascular treatment.

Splenic arteriovenous fistula (SAVF) is an unusual cause of portal hypertension, and is rarely associated with an infective aetiology. It is often difficult to identify SAVF clinically, and thus, radiological modalities are invariably required for diagnosis and treatment. We herein describe a case of SAVF occurring in a patient with compensated cirrhosis as a sequel to salmonella gastroenteritis, and presenting with acute gastric variceal bleeding. Selective transcatheter embolisation of the splenic artery was effective in controlling bleeding.

Endovascular repair of a Streptococcus pneumonia-induced aortitis complicated by an iliacocaval fistula.

PURPOSE: To describe the successful endovascular treatment and follow-up of a patient with a Streptococcus pneumonia-induced right iliacocaval fistula. CASE REPORT: A 82-year-old man was diagnosed with a right iliacocaval fistula, as a result of Streptococcus pneumoniae infection of the distal aorta and proximal right common iliac artery. After antibiotic treatment, he was initially unsuccessfully treated with balloon expandable covered stents. Then, the fistula was excluded by an aortamonoiliac endograft to the left common iliac artery, and occluders in the distal and proximal right common iliac artery followed by a femoral-femoral crossover bypass. Postoperatively patient was treated with prolonged antibiotics. After a follow-up of 20 months, there are no signs of active infection, endoleak, or fistula, both clinically and on 2-deoxy-2-[F18]fluoro-D-glucose positron emission tomography/computed tomography. CONCLUSION: In selected patients, complicated infectious disease of the aorto-iliac tract may be treated successfully with an endograft and prolonged antibiotics.

[Vascular Aspergillus infection in two recipients of kidneys from the same donor]. / Infección vascular por Aspergillus en dos receptores de injertos renal del mismo donante.

We describe a clinical case of two patients who received a cadaveric renal graft from the same donor in a multi-organ extraction procedure. The donor was a 39-years-old woman who died of intracranial tumour. A benign ganglioma was shown in biopsy. The two recipients received the same immunosuppressive regimen. Induction comprised cyclosporin A, steroids and basiliximab while cyclosporin A and steroids were used in maintenance immunosuppression. The A patient was a 53-year-old woman with chronic renal failure due to chronic pyelonephritis. She had been undergoing periodic haemodialysis for five years. She was hospitalised for sciatic pain refractory to rest and analgesics 35 days after transplantation. Two days later, her graft function deteriorated. Ultrasonography ruled out a urinary tract obstruction. Cyclosporine levels was normal. It was interpreted as an acute rejection episode and was treated with boluses of methylprednisolone (500 mg for 3 days). At the same time, her right leg began to show paraesthesia, coldness and a decreased arterial pulse. A spinal magnetic nuclear resonance was performed. It showed an aneurysm of right common iliac artery (fig. 1). An arteriography confirmed the existence of a pseudoaneurysm and an arteriovenous fistula to inferior vena cava (fig. 2). The B recipient was a 56-year-old woman with chronic renal failure due to chronic pyelonephritis. She required haemodialysis for two years. In the 4th month after transplantation her graft function deteriorated. Graft biopsy did not show acute cellular rejection, so she was kept on immunosuppressive treatment. A second graft biopsy was taken and no changes with the previous one was observed. Renal function deteriorated and haemodialysis was required. During the 6th month she began to show paraesthesia, coldness and decreased arterial pulse in her right leg. Ultrasonography showed pyelocaliectasis with an adjacent solid-liquid mass, abdominal CT scan confirmed. Arteriography proved the presence of a pseudoaneurysm of the right common iliac artery (fig. 3). Transplantectomy and pseudoaneurysm resection was performed in the two cases. Culture analysis revealed fungi identified as Aspergillus in both pseudoaneurysms. Medical treatment was started immediately with liposomal amphotericin B. The clinical evolution of the two recipients were different. While recipient A died, B patient recovered, requiring haemodialysis.

Infección vascular por Aspergillus en dos receptores de injertos renal del mismo donante / Vascular aspergillus infection in two renal recipients from the same donor

El caso clínico aquí descrito es el de dos pacientes que recibieron un injerto renal procedente del mismo donante, una mujer de 39 años fallecida a consecuencia de un tumor cerebral benigno. Los dos receptores iniciaron tratamiento inmunosupresor con ciclosporina A, esteroides y basiliximab, manteniéndose posteriormente con ciclosporina A y esteroides. La paciente A, una mujer de 53 años, padecía una insuficiencia renal crónica terminal (IRCT) secundaria a pielonefritis crónica, llevando en el momento del trasplante cinco años en programa de hemodiálisis. A los 35 días post-trasplante comenzó con clínica de ciatalgia derecha homolateral al injerto, refractaria a tratamiento analgésico. El día 37, presentó deterioro de la función renal que fue interpretado como un episodio de rechazo agudo y tratado como tal. Al mismo tiempo refirió parestesias con frialdad y disminución del pulso arterial periférico en la pierna derecha. Se le realizó una resonancia magnética donde se apreció la existencia de un pseudoaneurisma en la arteria ilíaca con una fístula arteriovenosa a cava inferior, que posteriormente fue confirmado mediante la realización de arteriografía. La paciente B, se trata de una mujer de 56 años, con IRCT secundaria a pielonefritis crónica en hemodiálisis previa durante 2 años. En el cuarto mes posttrasplante presentó un deterioro de la función renal. Se descartó la existencia de rechazo agudo mediante la realización de biopsia renal, manteniéndose el mismo tratamiento inmunosupresor. Debido al deterioro de la función renal, la paciente volvió a programa de hemodiálisis. Al sexto mes, desarrolló un cuadro de parestesias, frialdad y disminución del pulso arterial periférico en la pierna derecha homolateral al injerto. Mediante ecografía se apreció ectasia renal y una masa adyacente. Se realizó una tomografía que confirmó la existencia de una masa sólido-líquida. Mediante arteriografía se identificó como un pseudoaneurisma. En los dos casos se realizó nefrectomía del injerto, junto con resección del pseudoaneurisma y ligadura de la arteria ilíaca. El estudio histológico de los pseudoaneurismas reveló la presencia de Aspergillus y se inició tratamiento con anfotericina B liposomal. La evolución clínica de las dos pacientes fue diferente. La paciente A falleció debido a complicaciones secundarias a una segunda intervención quirúrgica por recibida del aneurisma. La paciente B presentó una evolución favorable manteniéndose en la actualidad en programa de hemodiálisis (AU)

We describe a clinical case of two patients who received a cadaveric renal graft from the same donor in a multi-organ extraction procedure. The donor was a 39-years-old woman who died of intracraneal tumour. A benign ganglioma was shown in biopsy. The two recipients received the same inmunosupressive regimen. Induction comprised cyclosporin A, steroids and basiliximab while cyclosporin A and steroids were used in maintenance immunosupression. The A patient was a 53-years-old woman with chronic renal failure due to chronic pyelonephritis. She had been undergoing periodic haemodialysis for five years. She was hospitalised by sciatic pain refractive to rest and analgesics 35 days after transplantation. Two days later, her graft function deteriorated. Ultrasonography ruled out a urinary tract obstruction. Cyclosporine levels was normal. Was interpreted as an acute rejection episode and was treated with boluses of methylprednisolone (500 mg for 3 days). At the same time, her right leg began to show paraesthesia, coldness and a decreased of arterial pulse. A spinal magnetic nuclear resonance was performed. It showed an aneurysm of right common iliac artery (fig. 1). An arteriography confirmed the existence of a pseudoaneurysm and an arteriovenous fistula to inferior vena cava (fig. 2). The B recipient was a 56-years-old woman with chronic renal failure due to chronic pyelonephritis. She required haemodialysis for two years. In the 4th month after transplantation her graft function deteriorated. Graft biopsy did not show acute cellular rejection. So she was kept on immunosupressive treatment. A second graft biopsy was taken and no changes with the previous one was observed. Renal function deteriorated and haemodialysis was required. During the 6th month she began to show paraesthesia, coldness and decreased of arterial pulse in her right leg. Ultrasonography showed pyelocaliectasis with an adjacent solidliquid mass, abdominal CT scan confirmed. Arteriography proved the presence of a pseudoaneurysm of the right common iliac artery (fig. 3). Transplantectomy and pseudoaneurysm resection was taken in the two cases. Culture analysis revealed fungi identified as Aspergillus in both pseudoaneurysm. Medical treatment was started immediately with liposomal amphotericin B. The clinical evolution of the two recipients were different. While recipient A died, B patient recovered requiring haemodialysis (AU)

Infectious arterial aneurysms: patterns and treatment.

PURPOSE: To evaluate patterns and evolution of treatment of infectious arterial aneurysms in a 15 year period. MATERIAL AND METHOD: Eight patients bearing 8 arterial aneurysms: 4 aorto-iliac, 1 of the internal carotid, 1 of the posterior tibial, 1 of the cubital, 1 of the internal carotid artery. For the aorto-iliac aneurysms treatment consisted in resection extra-anatomic by-pass in 2, "in situ" prosthetic grafting in the other 2. Extra-abdominal aneurysms were treated by excision/"in situ" vein grafting in two cases and simple resection in other two cases. RESULTS: One post-operative death occurred, due to rupture of a ligated aortic stump. No death or major complication occurred after "in situ" treatment of aorto-iliac aneurysms and, overall, in extra-aortic aneurysms. CONCLUSIONS: Staphylococcus and miceti have become the most frequently encountered causative agents. "In situ" grafting together with aggressive antibiotic therapy became the preferred method in the recent years and yielded good results.

Estenosis aórtica calcificada por endocarditis bacteriana experimental curada / Calcified aortic stenosis in experimental infectious endocarditis

Se estudia la participación de la endocarditis bacteriana en la génesis de estenosis aórtica calcificada. A nueve perros se les produjo fístula arterio-venosa femoral por el método de Lillehei y bacteriemia por inyección intravenosa de Streptococus mitis sensible, entre otros antibióticos, a la penicilina. Y se les inyectaron por vía intravenosa 10 ml diarios del cultivo de Streptococus mitis (1 X 10/10 bacterias) durante 15 días consecutivos. Los animales fueron sacrificados entre 28 y 102 días después de terminada la inoculación y tras haberles inyectado diariamente un millón de unidades y penicilina benzotínica. En un perro, se observó endocarditis bacteriana tanto en la mitral como en la aorta y en otros tres, entenosis aórtica calcificada con grandes depósitos calcéreos en el cuerpo y bordes valvulares. Estos mostraban una estenosis irregular y notable del orificio aórtico, de manera semejante a las observadas en el hombre