Il trattamento chirurgico nella sindrome di Budd-Chiari primitiva : una terapia in evoluzione

Background. Budd-Chiari syndrome (BCS) is an uncommon form of portal hypertension caused by obstruction of the hepatic venous outflow. Methods. From 1969 to 1997, 19 patients (7 men and 12 women, with a mean age of 37.6 years) affected with primary BCS were treated. In most of the cases no etiologic factors were identified; in the remaining cases the etiology was associated to polycythemia vera, use of oral contraceptives, presence of endoluminal membranes and repeated episodes of sepsis. Three patients with membranous occlusion of the major hepatic veins were treated by percutaneous placement of a self-expanding metallic stent, inserted by means of a transjugular or transhepatic approach. The remaining 16 patients underwent a side-to-side porto-caval shunt, which required the interposition of a graft in 5 cases. In 2 patients with a significant caval obstruction a metallic vascular stent was placed into the narrowed tract of inferior vena cava, before shunting, by means of a transfemoral venous approach. Results. One patient died within the first 30 postoperative days. The 18 survivors were followed for a mean of 66.7 months. The 5-year survival rate was 83%. Conclusions. Primary BCS requires different therapies depending on the stage of disease. The fulminant or chronic forms with irreversible hepatic damage, need a definitive treatment, such as orthotopic liver transplantation. On the contrary, in the acute or subacute forms, characterized by reversible hepatic injury, the porto-systemic shunt represents the most effective treatment. The patients with bad hepatic risk can be treated by using the new procedures of interventional radiology. In both cases preliminary caval stenting is necessary if the syndrome is complicated by a significant obstruction of the inferior vena cava

Outbreak of NDM-1-producing Enterobacteriaceae in northern Italy, July to August 2011.

Between July 2011 and August 2011, the New Delhi metallo-beta-lactamase 1 (NDM-1) gene was detected in Klebsiella pneumoniae and Escherichia coli isolates obtained from six patients hospitalised in four health- care facilities in northern Italy. The patient who had been hospitalised in New Delhi, India, from February to May 2011 and subsequently in the Bologna area, Italy, from May to July 2011, may have been the source of the outbreak. Our findings suggest ongoing spread of this carbapenem-resistance gene in Italy and high- light the need for intensive surveillance

Use of temocillin for identification of class D carbapenemases

Objectives. Currently, the main difficulty in laboratory confirmation of carbapenemases production concerns the identification of class D enzymes (OXA-48, OXA-181 and OXA-181-like), harbored in Enterobacteriaceae. Nevertheless, determination of susceptibility to temocillin provides an important indication of their possible presence. Aims of the study are to evaluate the susceptibility to temocillin of Enterobacteriaceae strains with reduced susceptibility to carbapenems, and to correlate it with the mechanism of resistance defined by genotypic tests, in order to assess the performance of the temocillin-susceptibility test. Methods. 231 strains of Enterobacteriaceae with reduced susceptibility to carbapenems at routine analysis (Vitek2 - BioMérieux), were tested, selected on the basis of the results to disk diffusion synergy test for detection and typing of carbapenemases (DDST, Rosco). These strains, belonging to different genus and species (Klebsiella, Escherichia, Enterobacter, Citrobacter, Proteus), have also been molecularly characterized with Hyplex® PCR (Amplex), a multiplex-PCR for blaKPC, blaVIM, blaIMP, blaNDM and blaOXA-48; their susceptibility to temocillin has been evaluated by disk diffusion test. Results. The 231 tested strains, divided according to DDST, gave the following results: - 33 class A carbapenemase-producers: 33 resulted positive for blaKPC, 31 subsceptible to temocillin, 2 resistant; - 41 class B (MBL) producers: 34 resulted positive for blaVIM (12 susceptible to temocillin, 22 resistant), and 7 for blaNDM (6 susceptible to temocillin, 1 susceptible); - 147 negative to DDST: 2 resulted positive for blaOXA-48, both resistant to temocillin, while the other 145 were negative to multiplex PCR and temocillin-susceptible; - 10 AmpC-producers: all resulted negative to multiplex PCR and susceptible to temocillin. Conclusion. Susceptibility to temocillin proved to be the only phenotypic test that allows the identification of class D carbapenemases-producers strains if combined to DDST, even if this study suggest that temocillin resistance, not performed with DDST, does not provide a result specific for class D carbapenemases. However its introduction in the laboratory routine could allow the clinical microbiologist to provide a reliable result about presence/absence of all main known carbapenemases in strains with reduced susceptibility to carbapenems; particularly, a negative result to DDST, associated with susceptibility totemocillin, allows to exclude with very high probability the presence of any carbapenemases (negative predictive value of 100%)

[Role of surgical therapy in the treatment of refractory ascites]

In 5-10% of cases ascites is not controlled by medical therapy and is defined refractory. These patients may be submitted to one of the four following surgical options: portal-systemic shunt, peritoneo-venous shunt, transjugular intrahepatic portal-systemic shunt, orthotopic liver transplantation. Although the portal-systemic shunt is efficient in clearing ascites, it does not improve the survival, which depends on liver function, and it is complicated by an important incidence of encephalopathy. Since the patients with refractory ascites and good hepatic risk are not usually many, it is possible to understand why derivative surgery has been disappointing with this indication. Although the peritoneo-venous shunt is associated with a significant rate of valve obstruction, it is an easy, effective and not expensive treatment. So, till now, it has been considered the first choice procedure of refractory ascites, if any situations, determinating the onset of postoperative complications, are not present. Recently a new method has been introduced in the therapy of portal hypertension, the transjugular intrahepatic portal-systemic shunt. This is a bloodless portal-systemic derivation and so it has caused great enthusiasm even if the available data are insufficient to give a definitive opinion on its role in management of ascites. Certainly the liver transplantation, which presents the great advantage to treat both the cirrhosis and its complications, seems to be the most rational therapy for these patients. However, at least for this moment, the well-known absence of organ donors makes still actual the palliative surgical measures

Rapid communications Outbreak of NDM-1-producing Enterobacteriaceae in

metallo-beta-lactamase 1 (NDM-1) gene was detected in Klebsiella pneumoniae and Escherichia coli isolates obtained from six patients hospitalised in four healthcare facilities in northern Italy. The patient who had been hospitalised in New Delhi, India, from February to May 2011 and subsequently in the Bologna area, Italy, from May to July 2011, may have been the source of the outbreak. Our findings suggest ongoing spread of this carbapenem-resistance gene in Italy and highlight the need for intensive surveillance. Outbreak description On 2 July 2011, we isolated Klebsiella pneumoniae harbouring the New Delhi metallo-beta-lactamase gene (bla), cultured from the urine of a patient (Patient ND

Outbreak of Citrobacter freundii carrying VIM-1 in an Italian Hospital, identified during the carbapenemases screening actions, June 2012.

Objective: The identification of patients colonized or infected with carbapenemase-producing Enterobacteriaceae (CPE), in order to control and prevent the global spread of multidrug-resistant (MDR) pathogens. Methods: From June 1 to June 15, 2012, eight Citrobacter freundii strains with reduced susceptibility to carbapenems were isolated from rectal swabs of hospitalized patients during active screening following the detection of a Klebsiella pneumoniae carbapenemase (KPC) -positive patient on the ward. All isolates were analyzed phenotypically and molecularly by PCR and sequencing. Genotype clustering was performed by multilocus sequence typing (MLST) analysis. Results: The isolates showed high rates of multidrug resistance profile. A phenotypic assay for carbapenemase production suggested the presence of metallo-b-lactamase (MBL). The blaVIM-1 gene was detected in all imipenem-resistant C. freundii isolates. MLST showed that the C. freundii isolates shared the same sequence type (ST). Phylogenetic analysis revealed a strict relationship with an ST5 C. freundii isolate from a diarrhea patient in China. Conclusions: Our findings showed that the active surveillance program for CPE was useful, not only for the detection of KPC-producers, but also to identify and control the spread of other MDR pathogens that could expand the spectrum of circulating MDR pathogens

Machine learning-based typing of Salmonella enterica O-serogroups by the Fourier-Transform Infrared (FTIR) Spectroscopy-based IR Biotyper system

Background: Salmonella enterica is among the major burdens for public health at global level. Typing of salmonellae below the species level is fundamental for different purposes, but traditional methods are expensive, technically demanding, and time-consuming, and therefore limited to reference centers. Fourier transform infrared (FTIR) spectroscopy is an alternative method for bacterial typing, successfully applied for classification at different infra-species levels. Aim: This study aimed to address the challenge of subtyping Salmonella enterica at O-serogroup level by using FTIR spectroscopy. We applied machine learning to develop a novel approach for S. enterica typing, using the FTIR-based IR Biotyper® system (IRBT; Bruker Daltonics GmbH & Co. KG, Germany). We investigated a multicentric collection of isolates, and we compared the novel approach with classical serotyping-based and molecular methods. Methods: A total of 958 well characterized Salmonella isolates (25 serogroups, 138 serovars), collected in 11 different centers (in Europe and Japan), from clinical, environmental and food samples were included in this study and analyzed by IRBT. Infrared absorption spectra were acquired from water-ethanol bacterial suspensions, from culture isolates grown on seven different agar media. In the first part of the study, the discriminatory potential of the IRBT system was evaluated by comparison with reference typing method/s. In the second part of the study, the artificial intelligence capabilities of the IRBT software were applied to develop a classifier for Salmonella isolates at serogroup level. Different machine learning algorithms were investigated (artificial neural networks and support vector machine). A subset of 88 pre-characterized isolates (corresponding to 25 serogroups and 53 serovars) were included in the training set. The remaining 870 samples were used as validation set. The classifiers were evaluated in terms of accuracy, error rate and failed classification rate. Results: The classifier that provided the highest accuracy in the cross-validation was selected to be tested with four external testing sets. Considering all the testing sites, accuracy ranged from 97.0% to 99.2% for non-selective media, and from 94.7% to 96.4% for selective media. Conclusions: The IRBT system proved to be a very promising, user-friendly, and cost-effective tool for Salmonella typing at serogroup level. The application of machine learning algorithms proved to enable a novel approach for typing, which relies on automated analysis and result interpretation, and it is therefore free of potential human biases. The system demonstrated a high robustness and adaptability to routine workflows, without the need of highly trained personnel, and proving to be suitable to be applied with isolates grown on different agar media, both selective and unselective. Further tests with currently circulating clinical, food and environmental isolates would be necessary before implementing it as a potentially stand-alone standard method for routine use