Incidence and significance of intraperitoneal anaerobic bacteria.
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To amplify recent interest in anaerobic infections following abdominal disease, trauma, or surgery, 512 consecutive patients subjected to emergency celiotomy had both aerobic and anaerobic cultures taken of peritoneal fluid as well as all complicating wound and intra-abdominal infections. Average time between peritoneal entry of abscess drainage and specimen incubating under anaerobic conditions was less than two minutes. During 4 of the seven study months, patients had antibiotic therapy randomized, with clindaymcin or cephalothin being sole parenteral agents and given intravenously prior to operation and for 5 days thereafter. Results demonstrated that anaerobes uniformly contaminate the peritoneal cavity whenever distal or obstructed intestine has been perforated, irrespective of the cause. Although all but one of the 123 complicating wound and intra-abdominal infections were due solely or at least in part to aerobic pathogens, 2/3 of such infections also contained one or more different anaerobic species acting in synergism with the aerobes. No significant difference in incidence of postoperative infection or in infecting bacteria could be found with respect to antibiotic administered or etiology of perforation. Indeed, duration of bacterial exposure to atmospheric oxygen was the most critical factor influencing culture recoverability of anaerobic organisms, likelihood of ensuing wound or peritoneal sepsis participated in by an anaerobe, and success in control of established infections harboring anaerobes. (+info)
Pre-emptive therapy against cytomegalovirus (CMV) disease guided by CMV antigenemia assay after allogeneic hematopoietic stem cell transplantation: a single-center experience in Japan.
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From April 1998 to March 2000, a cytomegalovirus (CMV) antigenemia-guided pre-emptive approach for CMV disease was evaluated in 77 adult patients who received allogeneic hematopoietic stem cell transplantation at the National Cancer Center Hospital. A CMV antigenemia assay was performed at least once a week after engraftment. High-level antigenemia was defined as a positive result with 10 or more positive cells per 50 000 cells and low-level antigenemia was defined as less than 10 positive cells. Among the 74 patients with initial engraftment, 51 developed positive antigenemia. Transplantation from alternative donors and the development of grade II-IV GVHD were independent risk factors for positive antigenemia. Ganciclovir was administered as pre-emptive therapy in 39 patients in a risk-adapted manner. None of the nine low-risk patients with low-level antigenemia as their initial positive result developed high-level antigenemia even though ganciclovir was withheld. Only one patient developed early CMV disease (hepatitis) during the study period. CMV antigenemia resolved in all but two cases, in whom ganciclovir was replaced with foscarnet. In eight patients, however, the neutrophil count decreased to 0.5 x 10(9)/l or less after starting ganciclovir, including three with documented infections and two with subsequent secondary graft failure. The total amount of ganciclovir and possibly the duration of high-dose ganciclovir might affect the incidence of neutropenia. We concluded that antigenemia-guided pre-emptive therapy with a decreased dose of ganciclovir and response-oriented dose adjustment might be appropriate to decrease the toxicity of ganciclovir without increasing the risk of CMV disease. (+info)
Repeated postpericardiotomy syndrome following a temporary transvenous pacemaker insertion, a permanent transvenous pacemaker insertion and surgical pericardiotomy.
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The postpericardiotomy syndrome is a well-known complication of opening and manipulating the pericardium. The occurrence of this syndrome following transvenous pacemaker insertion is very rare, and only 5 cases have been reported to date. The present patient repeated this syndrome 3 times in a short period following 3 different interventional techniques: a temporary transvenous pacemaker, a permanent transvenous pacemaker and surgical pericardiotomy. (+info)
Completeness and accuracy of voluntary reporting to a national case registry of laparoscopic cholecystectomy.
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OBJECTIVE: To validate completeness and accuracy of registry data reported from three randomly chosen departments contributing to The Danish National Registry of Laparoscopic Cholecystectomy, covering all departments offering chole cystectomy. DATA SOURCES: A total of 431 case reports representing cases of laparoscopic cholecystectomy in a 2-year period in three surgical departments. DESIGN: Comparison of case reports with reported data in The Danish National Registry of Laparoscopic Cholecystectomy. MAIN OUTCOME MEASURES: Rates of discrepancies, comparison of complication rates for cases in the registry and cases not reported to the registry. RESULTS: Completeness of registration was 69%, 80% and 99% respectively. A significantly higher degree of completeness was found in the only department with a formalized registration procedure. Inaccuracies were found in 28-49% of the cases, but none regarding serious complications such as bile duct injury or perioperative death. CONCLUSIONS: The information in the national registry may be accurate if the present findings can be extrapolated to the remaining departments in the country. The number of non-reported cases should be minimized by introducing a formalized procedure of handling and forwarding information to the registry. Continuous validation through external visits by registry staff to contributing departments may also be advisable. (+info)
Perfusionist-transmitted bacterial mediastinitis in a heart transplant recipient.
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We report the case of a 56-year-old man who developed bacterial mediastinitis with methicillin-resistant Staphylococcus aureus after undergoing heart transplantation. He had a history of insulin-dependent diabetes mellitus and prior cardiac surgery. To find the source of nosocomial infection, we cultured nasal swab specimens from all hospital personnel involved in this operation. We used antibiotic sensitivity profiling and pulsed-field gel electrophoresis to subtype the involved microorganism. The S. aureus isolates from the patient and the perfusionist were identical to each other and were different from the strains previously found in our hospital. It is almost certain that the S. aureus mediastinitis in this patient was transmitted from the perfusionist. We recommend obtaining cultures from hospital staff members when there is an outbreak of staphylococcal infection. (+info)
Wound infections involving infrainguinal autogenous vein grafts: a current evaluation of factors determining successful graft preservation.
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PURPOSE: The purpose of this study was to review the natural history and clinical outcome of patients with infrainguinal autogenous graft infection (IAGI), to evaluate the effectiveness of attempted graft preservation, to determine those variables associated with graft salvage, and to better determine optimal treatment. STUDY DESIGN: We retrospectively reviewed the records of patients undergoing infrageniculate vein grafts at three hospitals between 1994 and 2000 who had a wound infection involving the graft. Clinical and bacteriologic variables were analyzed and correlated with graft salvage, limb salvage, and clinical outcome. RESULTS: During this 7-year period, 487 patients underwent an infrageniculate vein graft, and 68 (13%) had clinical evidence of IAGI. Twenty-seven patients presented with drainage from the wound, 15 with wound separation and cellulitis, 18 with soft tissue infection extending to the graft, 4 with an abscess and cellulitis, and 4 with bleeding. Ten patients (15%) had systemic symptoms (defined as a white blood cell count > 15,000 and temperature > 38.5 degrees C). Forty infections developed in the thigh, 17 in the groin, and 11 in the lower leg. An anastomosis was exposed in 15 patients. Wound cultures were positive for bacteria in 52 patients, and most infections were due to Staphylococcus aureus (18 patients) and S epidermidis (12 patients). Pseudomonas was cultured from seven infections. Twelve patients had polymicrobial infections. The interval from operation to infection ranged from 7 to 180 days. All patients were treated with oral antibiotics, 48 after intravenous antibiotics. Forty-five patients had operative debridement, including 18 who had muscle flap coverage. Four patients presented with hemorrhage, and three had immediate graft ligation and one graft excision. Follow-up ranged from 5 to 68 months (mean, 24.3 months), with 61 patients currently alive. Two patients died as a result of the IAGI (mortality rate, 2.9%). One had undergone a below-knee amputation, and one had a nonhealed wound but intact limb. Overall, 61 wounds (91%) healed, 4 patients required below-knee amputations, and 3 wounds did not heal. Fifty-eight grafts remained patent, 6 thrombosed, and 4 were ligated to control hemorrhage. Of the 61 wounds that healed, the time required for healing ranged from 7 to 63 days. No patient with bleeding died because of the acute episode. No patient had delayed hemorrhage. All 18 patients treated with a muscle flap healed. Bleeding (P <.001), elevated white blood cell count (P <.029), fever (P <.001), and renal insufficiency (creatinine level > 1.5; P <.056) were the only variables statistically significant in predicting graft failure or limb loss. With the use of life-table analysis, graft patency was 94%, 72%, and 72% at 1, 3, and 5 years, and limb salvage was 97%, 92%, and 92% at the same intervals, respectively. CONCLUSIONS: Most patients with an IAGI can be successfully treated with graft and limb preservation. In contrast to earlier studies, an exposed anastomosis, interval to infection, or Pseudomonas infection is not associated with graft failure. Graft salvage is less likely in patinets with fever, leukocytosis, and renal insufficency, but because most grafts remained patent, graft preservation is recommended for these patients. Graft ligation or excision should be reserved for patients presenting with bleeding or sepsis. (+info)
A prospective audit of complex wound and graft infections in Great Britain and Ireland: the emergence of MRSA.
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BACKGROUND: a number of studies have examined the outcome of complex wound and graft infections, but most include small numbers of patients collected over a prolonged period of time. To date, there is little information on the clinical outcome of infections involving methicillin-resistant Staphylococcus aureus (MRSA). METHODS: between February 1998 and January 1999, two prospective multi-centre audits were performed in order to examine the current outcomes following (1) complex vascular wound infections and (2) graft infections in Britain and Ireland with particular reference to outcome associated with MRSA infection. RESULTS: seventy-five complex wound infections (Szylagyi II and III) were reported, with the commonest single organism being MRSA. Type II infections were associated with a 5% risk of death and/or amputation as opposed to 75% in those with a type III infection. Fifty-five graft infections were reported, with the commonest single organism being MRSA. Overall, 30 (55%) died or underwent amputation. MRSA wound and graft infections were associated with a significantly higher risk of amputation and prolonged hospital stay (but not of death) as compared with MRSA negative patients. CONCLUSIONS: in this audit, MRSA was the commonest single organism cultured in patients with complex wound and graft infections after vascular surgery. This represents a major change in the spectrum of causative organisms relative to other, older published series. MRSA infections contribute towards an increased risk of adverse outcome and prolonged hospital stay. (+info)
Diagnostic validity of computed tomography for mediastinitis after cardiac surgery.
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BACKGROUND: Optimal treatment based on appropriate early diagnosis is essential in managing mediastinitis after cardiac surgery. We evaluated the accuracy of thoracic computerised tomography (CT) in the diagnosis of mediastinitis. METHODS: Forty-one patients in whom we performed CT after cardiac surgery were classified into two groups as follows; Six cases had mediastinitis requiring a redo surgical intervention (Group M). Thirty-five cases recovered without mediastinitis (Group C). Comparisons of CT findings in both groups were made retrospectively. RESULTS: In group M, CT and re-operations were performed 6.3+/-2.5 days and 8.0+/-5.2 days after previous operation, respectively. All but one of redo surgical procedures were mediastinal lavage and omental transplantation. Two patients died due to septic shock and multiple organ failure. CT in group M showed a soft tissue mass with contrast enhancement in 4 patients, bilateral pleural effusion in 5, free gas appearance in 4, and sternal dehiscence or destruction in 2 patients. Consequently, we regarded 4 of the 6 patients in this group as showing postoperative mediastinitis radiographically. In group C, CT performed 16.6+/-7.1 days after operations revealed findings suggestive of mediastinitis in 6 patients. Therefore, in terms of the validity of CT for the diagnosis of mediastinitis, the sensitivity was 67% and the specificity was 83%. CONCLUSION: The sensitivity of CT for diagnosis of mediastinitis after cardiac operations is unsatisfactory. Diagnosis by seeking infective changes in a multidisciplinary way is important in dealing with mediastinitis. (+info)