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PubMed1996

[Primary cutaneous cryptococcosis and bacterial pneumonia caused by Pseudomonas aeruginosa in AIDS: clinical case and review of the literature].

BACKGROUND: Clinically symptomatic infection due to Cryptococcus neoformans is found in 5-10% of patients with AIDS. It usually appears as meningitis with or without associated blood stream infection. In the last years, severe Pseudomonas aeruginosa infections in HIV (+) patients, with a high morbidity and mortality, are increasingly reported. MATERIALS AND METHODS: A 27 year-old male HIV (+) patient, with previous opportunistic infections, was referred because of a nodular lesion on his left wrist, with an axillar homolateral lymph node of long-term evolution. Cryptococcus neoformans var. neoformans was isolated in pure culture from the lesion. Disseminated infection or affection of other organs was ruled out. Therapy with intravenous amphotericin B was initiated, but the patient developed an early nosocomial bacteremic pneumonia due to P. aeruginosa with a fatal outcome. A review of the literature about both complications in AIDS is carried out. RESULTS: The fungal clinical picture is compatible with primary cutaneous cryptococcosis that is a rare condition (12 clinical reports until 1993), of which only one case report in an AIDS patient has been described in 1994. Since 1990 severe infections due to P. aeruginosa in HIV(+) patients are increasingly reported, and pneumonias, bacteremias, catheter-related sepsis, urinary tract infections, intraabdominal infections, central nervous system and othorrhinolaryngologic infections have been described in patients with AIDS in the English-language literature. CONCLUSIONS: Primary cutaneous cryptococcosis is another rare form of infection with C. neoformans in patients with AIDS. The increasingly reported cases of severe infections due to P. aeruginosa could have important implications in the therapy of patients with AIDS.

Adult↗

PubMedDate not supplied

Infections in intraabdominal surgery. The EURESI Project. European Research Network on Surgical Infections.

The situation of clinical research in Europe must be improved substantially according to statements of scientists, managers and politicians. The analysis of requirements is available; however, there are no indications that the conclusion of the analysis is being converted into actual facts. Government programs, although originally conceived to improve the situation of clinical research, are used to maintain the status quo. The European Research Network on Surgical Infections (EURESI) concept has been developed by scientists and clinicians from European institutions and university hospitals to make the first steps possible in a new cooperation in European research. With regard to the essentials for clinical research, formulated according to a survey among research-oriented pharmaceutical companies, EURESI was successful in the following objectives: 1) competence in clinical research, 2) capacity for clinical studies, 3) internal quality control, 4) special know-how relevant to clinical studies, 5) performance according to a time plan, 6) interdisciplinianism, 7) contract partnership, 8) organization of research meetings. This special addendum includes presentations at the EURESI meeting in Heidelberg/Weinheim with special reference to the requirements for clinical studies in intraabdominal infections to further stimulate contact with the network.

Abdomen↗

PubMed1993

Risk factors for multiple organ system failure and death in critically injured patients.

BACKGROUND: This study was undertaken to evaluate the relative importance of factors related to the extent of multiple organ system failure (MOSF) and outcome in critical trauma. METHODS: We performed a retrospective case series analysis of 206 consecutive patients with trauma admitted to a surgical intensive care unit during a 5-year period. Multivariate methods were used to select independent factors related to the MOSF score and subsequent death. RESULTS: Multiple linear regression selected advancing age, prior chronic conditions, malnutrition, injury severity score (ISS), coma on admission, use of H2-receptor antagonists or antacids, number of blood transfusions, and intraabdominal infection as independent factors related to the MOSF score. Multiple logistic regression selected advancing age, chronic disease, ISS, and MOSF score as major predictors of death. CONCLUSIONS: Advancing age, prior chronic disease, malnutrition, coma on admission, and use of H2-receptor antagonists or antacids may impair host defenses of the gastrointestinal tract and predispose to invasive infection, thereby aggravating the severity of existing MOSF. These findings, together with the predominance of Enterobacteriaceae in patients with infection, suggest that bacterial translocation may be important in the late MOSF septic state. Although infection, particularly intraabdominal infection, is a major risk factor for MOSF, a nonspecific host response to critical trauma, as expressed by the ISS and transfusion requirement, and intestinal endotoxin may contribute to the development of the syndrome.

Adolescent↗

PubMed1997

In defense of routine antimicrobial susceptibility testing of operative site flora in patients with peritonitis.

The species and number of bacteria present at a surgical site correlate with postoperative wound infection. When organisms cultured from intraabdominal infections are resistant to the presumptive antimicrobial therapy, the incidence of postoperative wound and intraabdominal infections is significantly increased. Knowledge of operative site culture data allows identification of resistant organisms, leads to an early change in therapy, and guides selection of antimicrobials for treatment of postoperative complications. Anaerobic susceptibility data vary geographically, even differing within hospitals in the same city. Surveillance of resistance patterns of bacteria causing intraabdominal infections facilitates accurate initial therapy. Failure of treatment in the absence of bacteriologic results confirming appropriate antimicrobial therapy may be difficult to rationalize on a medicolegal basis. In summary, it is advisable for surgeons to perform cultures and susceptibility tests for both aerobic and anaerobic organisms present in intraabdominal infections.

Bacteria, Anaerobic↗

PubMedDate not supplied

Comparison of moxalactam with the combination of clindamycin and an aminoglycoside in the treatment of common surgical infections.

The efficacy and safety of moxalactam were compared with those of a combination of clindamycin and an aminoglycoside in a randomized study of therapy for 60 patients with the following surgical infections: intraabdominal or pelvic infections (12 patients), abscesses (13 patients), and severe infections of extremities (35 patients). These infections were equally distributed between the two treatment groups, except that, according to the randomization process, a majority of patients with intraabdominal infections received moxalactam therapy. Surgery was used as adjunctive therapy when necessary. One adverse reaction--fever and leukocytosis with eosinophilia--was due to continued administration of moxalactam. No significant adverse reaction was observed in the patients treated with the clindamycin-aminoglycoside combination. Although the number of isolated organisms resistant to the antibiotics was similar within each treatment regimen, an alarmingly high percentage of gram-positive cocci were intermediately sensitive to moxalactam in vitro. Even in the presence of resistant organisms, moxalactam therapy was as effective as the clindamycin-aminoglycoside therapy when surgical debridement or drainage was properly timed and executed.

Abscess↗

PubMed2001

[Results and prospects of treatment of general forms of peritonitis].

956 patients with general peritonitis were operated: 596 patients--for diffuse peritonitis, 360--for general peritonitis. The causes of peritonitis were: perforating gastroduodenal ulcers (454), acute destructive appendicitis (190), acute destructive cholecystitis (82), perforation of small intestine and colon (96), postoperative peritonitis (80), other diseases (54). In low degree of bacterial contamination of abdominal cavity (not more Ig 5 CFU/g) operations were completed without abdominal drainage, laparoscopic variant of the operation being optimal. In postoperative period, out of 691 patients with low degree of bacterial contamination wound infection was in 7.9%, intraabdominal infection--in 2.5%, polyorganic insufficiency--in 1.0%; lethality was 5.9%. In high degree of bacterial contamination (more Ig 5 CFU/g) and massive unremovable fibrinous patch on the peritoneum the programmed revisions and sanations of abdominal cavity were performed, sometimes--control laparoscopic revisions. In postoperative period of 256 patients with high degree of bacterial contamination wound infection arose in 6.0%, intraabdominal infection--in 4.2%, polyorganic insufficiency [symbol: see text] in 42.6%; lethality was 18.1%.

Adult↗

PubMed1992

[Fascia dehiscence--cause and prognosis].

During a period of 5 years, 4476 interventions in abdominal surgery were prospectively analyzed. The incidence of fascial dehiscence was 0.7% (n = 30). Seventeen of these patients underwent surgery on account of intraabdominal infection (total incidence of intraabdominal infection 4.4%). Fascial dehiscence developed in 22 out of 30 patients (73%) after emergency surgery. All of them had to be operated out of routine surgical schedule with the exception of four patients. Using multivariate stepwise logistic regression analysis, main determinant factors in fascial dehiscence were the ASA score (p = 0.0001), reflecting the severity of primary or concomitant diseases, and wound infection (p = 0.0075), mostly due to intraabdominal contaminations. Fascial dehiscence was associated significantly with a higher morbidity, reflected by longer inpatient management. Nevertheless, the overall lethality of 20% was associated to serious primary or concomitant diseases. Therefore, the results emphasize the significance of diligent preoperative work-up. Adequate treatment for concomitant disorders should be performed preoperatively, whenever possible even in emergency surgery.

Abdomen↗

PubMed2006

Tigecycline: first of a new class of antimicrobial agents.

Tigecycline is the first commercially available member of the glycylcyclines, a new class of antimicrobial agents. The glycylcyclines are derivatives of the tetracycline antibiotics, with structural modifications that allow for potent gram-positive, gram-negative, and anaerobic activity, including certain multidrug-resistant strains. The enhanced activity can be attributed to stronger binding affinity and enhanced protection against several mechanisms of resistance that affect other antibiotic classes such as tetracyclines. Tigecycline exhibits generally bacteriostatic action by reversibly binding to the 30S ribosomal subunit and inhibiting protein translation. In vitro activity has been demonstrated against multidrug-resistant gram-positive pathogens including methicillin-resistant and glycopeptide-intermediate and -resistant Staphylococcus aureus, as well as vancomycin-resistant enterococci. Multidrug-resistant gram-negative pathogens, such as Acinetobacter baumannii and extended-spectrum beta-lactamase-producing Klebsiella pneumoniae and Escherichia coli, are typically highly susceptible to tigecycline. The drug also has displayed significant activity against many clinically important anaerobic organisms. This agent demonstrates a predictable pharmacokinetic profile and minimal drug interactions, and is generally well tolerated, with nausea being the most common adverse event. It was approved in June 2005 for the treatment of complicated skin and skin structure infections (SSSIs) and complicated intraabdominal infections. Currently, a limited number of broad-spectrum antimicrobials are available to combat multidrug-resistant organisms. The addition of new agents is essential to limiting the spread of these pathogens and improving outcomes in patients with these types of infections. Tigecycline has demonstrated promising results in initial in vitro and clinical studies for SSSIs and complicated intraabdominal infections; however, further clinical experience will clarify its role as a broad-spectrum agent.

Animals↗

PubMed2003

Linezolid for the treatment of multidrug-resistant, gram-positive infections: experience from a compassionate-use program.

Linezolid was provided for treatment of multidrug-resistant, gram-positive infections through a compassionate-use program. Patients (n=796) received 600 mg of linezolid intravenously or orally every 12 h (828 treatment courses). Bacteremia was present in 46% of infections, endocarditis was present in 10.6%, and line-related infections were present in 31.1%. Other infections included intraabdominal infections (15.1%), complicated skin and skin-structure infections (13.3%), and osteomyelitis (10.7%). Causative pathogens included vancomycin-resistant enterococci (66.3%) and methicillin-resistant staphylococci (22.1%). Clinical intent-to-treat (ITT) outcomes in the evaluable population were as follows: cure, 73.3%; failure, 6.8%; and indeterminate, 19.9%. Microbiological ITT outcomes in evaluable patients were as follows: cure, 82.4%; failure, 14.1%; and indeterminate, 3.5%. At the test of cure assessment, the clinical cure and microbiological success rates were 91.5% and 85.8%, respectively. The most common adverse events possibly related to linezolid use were gastrointestinal disturbances (9.8% of cases), thrombocytopenia (7.4% of cases), decreased hemoglobin/hematocrit levels (4.1% of cases), and cutaneous reactions (4.0% of cases). Linezolid provided high rates of clinical cure and microbiological success in this complicated patient population, with very good overall tolerance.

Acetamides↗

PubMed2006

Efficacy and safety of drotrecogin alfa (activated) for the therapy of surgical patients with severe sepsis.

BACKGROUND: The efficacy of therapy with drotrecogin alfa (activated) (DrotAA) (recombinant human activated protein C) for surgical patients with severe sepsis has been questioned, and there is concern that patients who have undergone surgery recently may be at increased risk of bleeding complications from the drug. This review was performed to analyze recent data and clinical trends in the management of surgical patients with severe sepsis with respect to the efficacy and safety of therapy with DrotAA. METHODS: Review and synthesis of the pertinent English-language literature. RESULTS: Source control is the mainstay of therapy for surgical infections, including intraabdominal infections, whereas antibiotics, fluid resuscitation, and support of visceral organ function are necessary adjuncts. Therapy with DrotAA can be given to surgical patients, albeit with some delay (most protocols specify a 12-h wait after major surgery to mitigate the perceived increased risk of bleeding), but efficacy as well as safety have been questioned. In the pivotal PROWESS clinical trial, DrotAA therapy did not appear to be efficacious for surgical sepsis, but rigorous scrutiny of surgical indications and adequacy of source control by blinded reappraisal of the PROWESS database suggested that DrotAA therapy may be effective for surgical patients at high risk of death (Acute Physiology and Chronic Health Evaluation [APACHE] II score>or=25 points). Several comparable studies have now been aggregated in the INDEPTH database, which shows a significant reduction in mortality (OR 0.66; 95% CI 0.45-0.97) for therapy with DrotAA of surgical patients with severe sepsis and a high risk of death. The risk of bleeding is higher in surgical patients compared with DrotAA-treated non-surgical patients, but there is a substantial improvement in survival with DrotAA treatment. In contrast, surgical patients at a lower risk of death do not benefit from therapy with DrotAA but are placed at risk for bleeding. CONCLUSION: Accumulating experience indicates that surgical patients with severe sepsis and a high risk of death (APACHE II>or=25 points) have a significantly lower mortality rate if treated with DrotAA. The increased risk of bleeding associated with therapy is acceptable given the clear improvement in survival. Surgical patients with sepsis who are at lower risk of death do not appear to benefit from therapy with DrotAA, which should be withheld in most circumstances because of the increased risk of bleeding.

APACHE↗

PubMedDate not supplied

Cefoxitin: an overview of clinical studies in the United States.

Cefoxitin, a new cephamycin antibiotic that is active against aerobic and anaerobic bacteria, was studied by 35 investigators in the United States. Of 657 patients eligible for evaluation of efficacy of the compound, 69% were cured and 92% were cured or improved on clinical grounds. Bacteriologic response to therapy with cefoxitin was equally good for infections due to gram-positive cocci (94% cured), gram-negative bacilli (87% cured), and anaerobes (95% cured). Cefoxitin was effective clinically and bacteriologically in the eradication of infections due to organisms resistant to ampicillin, cephalothin, chloramphenicol, tetracycline, and aminoglycosides. Overall rates of favorable response to cefoxitin therapy by disease were: lower respiratory tract infections, 90%; urinary tract infections, 87%; intraabdominal infections, 90%; gynecologic infections, 94%; and septicemia, 84%. Cefoxitin was tolerated well, and major abnormalities of hematologic, hepatic, renal, or central nervous system function were encountered rarely. Resistance to cefoxitin did not develop among gram-negative cocci, anaerobes, or gram-negative bacilli in the medical centers in which the antibiotic was used.

Bacterial Infections↗

PubMed1993

Enterococcus, an emerging pathogen.

OBJECTIVE: To review the bacterial genus Enterococcus with respect to its epidemiology, specific infections in humans, mechanisms of resistance and tolerance, and antimicrobial treatment. DATA SOURCES: A MEDLINE search of English-language journal articles published from 1977 to 1992 was completed. Articles published prior to 1977 were identified through Index Medicus and from references appearing in the bibliographies of other journal articles. Information also was acquired from abstracts, personal communication with infectious disease specialists with active research in the area of enterococcal infection, and conference proceedings. STUDY SELECTION: In vitro data; animal models of enterococcal infection; case reports; and case-controlled, cohort, and randomized controlled trials in humans were evaluated for relevant information. DATA EXTRACTION: Studies were evaluated by their methodologic strength (e.g., randomized controlled trial), reporting of clinically relevant outcomes (e.g., clinical response to antimicrobial therapy), statistical analyses, and accountability of all patients who entered the study. DATA SYNTHESIS: The incidence of enterococcal infections has increased in recent years and enterococci are now the second most frequently reported nosocomial pathogens. Enterococcus faecalis is the pathogen responsible for most enterococcal infections seen today; it has been implicated as an important cause of endocarditis, bacteremia, urinary tract infections, and intraabdominal infections. CONCLUSIONS: Enterococcal infection is of particular concern clinically because of its resistance to several antibiotics. Controlled comparative clinical trials of antimicrobial therapy in humans are lacking for several enterococcal infections. Therefore, the recommendations for antimicrobial therapy presented in this review are guidelines that reflect our current understanding of antibiotics used for enterococcal infection.

Abdomen↗

PubMed2006

Tigecycline: a new glycylcycline antimicrobial agent.

PURPOSE: The pharmacology, spectrum of activity, pharmacokinetics, clinical efficacy, adverse events, dosage and administration, drug interactions, and place in therapy of tigecycline are reviewed. SUMMARY: Tigecycline is the first of a new class of antimicrobials, the glycylcyclines, to receive approved labeling from the Food and Drug Administration. Similar to tetracyclines, glycylcyclines contain the central four-ring carbocyclic skeleton, with a substitution at the D-9 position. This substitution confers expanded broad-spectrum activity and defense against antimicrobial efflux pumps and ribosomal protection mechanisms. Tigecycline covers a broad spectrum of gram-positive (including resistant isolates), gram-negative (including extended-spectrum beta-lactamase producing organisms), and anaerobic pathogens. It does not exhibit activity against Pseudomonas aeruginosa and Proteus species. Clinical efficacy has been demonstrated in complicated skin and skin structure infections and intraabdominal infections. Tigecycline is administered intravenously and exhibits linear pharmacokinetics. The drug does not undergo extensive metabolism and works independently of the cytochrome P-450 isoenzyme system and therefore does not affect medications metabolized by these enzymes. Tigecycline is administered as a 100-mg i.v. loading dose followed by 50 mg i.v. every 12 hours. Hepatic dosage adjustment is necessary for severe disease; however, no dosage adjustments are necessary for patients with renal impairment. CONCLUSION: Tigecycline is an alternative agent available for the treatment of resistant gram-negative and gram-positive infections, especially in patients with a history of a penicillin allergy or antimicrobial-related toxicities.

Animals↗

PubMed2005

New onset fever in the intensive care unit.

Fever is defined as a core body temperature of >38.3 degrees C or 101 degrees F. About 50% of fevers in the ICU are due to infectious causes. Absence of fever in patients with infection heralds a poor prognosis. Temperatures between 102 degrees F-106 degrees F are more likely to be due to infection. The common infectious causes of fever are pneumonia, urosepsis, line infections and intraabdominal infections. Temperatures <102 degrees F or >106 degrees F are usually due to non-infectious causes like deep venous thrombosis, infusion reactions, aspiration, drug fever and the neuroleptic malignant syndrome. Fever should be distinguished from hyperthermia as antipyretics are ineffective in the latter. Inappropriate use of antibiotics selects resistant bacterial strains, but delay in treating infection could increase mortality. A structured approach is therefore required in order to correctly diagnose and treat fever in critically ill patients.

Body Temperature↗

PubMed1991

[Sulbactam in combination with mezlocillin, piperacillin or cefotaxime. Clinical and bacteriological results in the treatment of severe bacterial infections].

An open multicenter study on inpatients of 12 german hospitals was performed to investigate efficacy and safety of sulbactam in combination with mezlocillin, piperacillin or cefotaxim in severe bacterial infections. In total 155 patients were enrolled. The following infections were diagnosed: 48 lower respiratory tract infections, 66 intraabdominal infections, 34 skin/soft tissue infections including post operative wound infections and 5 complicated urinary tract infections. 55 patients received 3 daily doses of 4 g mezlocillin + 1 g sulbactam, 52 patients received 3 daily doses of 4 g piperacillin + 1 g sulbactam and 48 patients received 3 daily doses of 2 g cefotaxim + 1 g sulbactam. Antibiotics and sulbactam were administered concomitantly via intravenous short infusion. Mean duration of therapy was 8 days. Endpoints for assessment of therapeutic efficacy were cure (complete resolution of pretreatment signs and symptoms of the infection) or improvement (marked reduction or partial disappearance or pretreatment signs and symptoms, no further antibiotic therapy required) as well as eradication of pretreatment pathogens. 141 (92%) of 153 evaluable patients were successfully treated (98 cures and 43 improvements), therapy failed in 12 patients (7.8%). Success rates of the 3 sulbactam combinations were almost identical: 91% for mezlocillin/sulbactam, 92% for piperacillin/sulbactam and 93% for cefotaxim/sulbactam. 106 patients (68.4%) were also bacteriologically evaluable. In these patients 192 bacterial pathogens were isolated prior to study therapy, 55 patients had mixed infections. In 96 patients (90%) pretreatment pathogens were eradicated (180 strains = 94%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1995

Operative site bacteriology as an indicator of postoperative infectious complications in elective colorectal surgery.

Toward the completion of elective colorectal operations, 75 patients had qualitative aerobic and anaerobic cultures of specimens obtained from peritoneal irrigation fluid, anastomoses sites, and abdominal wound irrigation fluid to determine if a correlation exists between intraoperative flora and postoperative infectious complications. Patients enrolled in this prospective study received a mechanical bowel prep and a 12-18 hour course of perioperative intravenous antibiotics. Comparisons were made between the 60 (80%) patients who had no postoperative infections and the 15 (20%) who developed postoperative infectious complications (9 wound infections, 6 intraabdominal infections). There were significantly more low anterior resections in patients who developed postoperative infection compared to those who had no postoperative infection (26% vs 2%), while there were more colocolostomies in the group with no infections (38% vs 7%). Streptococcus spp., Bacteroides fragilis group, and Escherichia coli were the most commonly isolated organisms from each of the three sites sampled. Isolation of > or = 3 organisms from incisional wound cultures (P = 0.017) and < or = 4 organisms from peritoneal irrigation (P = 0.009) or anastomotic culture (P = 0.004) correlated with development of postoperative infectious complications. Thus, patients with infectious complications had significantly more isolates than those without infectious complications, and were more likely to have had a low anterior resection. These data suggest that future clinical studies should reexamine the duration of perioperative antimicrobials based on early laboratory reports of qualitative and quantitative operative site bacteriology.

Abdomen↗

PubMedDate not supplied

Primary repairing in penetrating colon injuries.

BACKGROUND/AIMS: The large bowel is injured in about 10% of penetrated abdominal injuries. Primary repair with colostomy has been discussed recently. MATERIALS AND METHODS: Between 1987 and 1995, sixty-five patients were operated on with penetrated colon injuries were treated with primary repair without colostomy. Any patient with one or more of the following criteria was excluded: Age > 60 years, blood pressure < 80/60 mmHg, time from injury to treatment > 8 hours, Penetrating abdominal trauma index > 50. RESULTS: The mean age of the patients was 31 and female/male ratio was 1/7. Fifty-one patients (78.5%) were exposed to colon injury by stabbing and 14 patients (21.5%) by gunshot. The most frequently injured segment was the transverse colon (36.9%). The liver was the most commonly injured organ associated with colon injury (32.3%). Colon wounds of 48 patients (73.8%) were treated with simple repair consisting of meticulous debridement. All gunshot wounds (14 patients) and 3 of the stab wounds were treated with segmentary resection and two layered anastomosis because of the massive colonic wall injury and/or impairment of the blood supply. The most common postoperative complication was wound infection (12.3%). Intraabdominal infection and leakage of the anastomosis were not observed. CONCLUSION: Primary repair or, if necessary, segmentary resection and anastomosis will be more appropriate in civilian colon injuries.

Adult↗

PubMed1985

Nitrogen-sparing effect of lipid emulsion in septic dogs.

Effects of intravenously administered lipid emulsion on the nitrogen balance in dogs with intraabdominal infection were investigated. The nitrogen balance in dogs supported by parenteral nutrition (PN) with glucose alone was superior to that in dogs supported by PN with glucose and lipid emulsion, in the absence of intraabdominal infection. On the other hand, the nitrogen balance in dogs supported by PN with glucose and lipid emulsion was superior to that with glucose alone, in the presence of intraabdominal infection. Dogs with intraabdominal infection had an insulin-resistance inability to effectively utilize glucose.

Animals↗