Tumor mozga kao prototip teškog moždanog oštećenja u bolesnika sa “sindromom niskog t3”

The purpose of our study was to contribute to better understanding of cerebrospinal fluid (CSF) as a valuable biological material in the research of brain tumors within the “low T3 syndrome”, and to discuss the role of thyroid hormones in the central nervous system in subjects with severe cerebral lesions. We studied the levels of total triiodothyronine (tT3), total thyroxine (tT4), free triiodothyronine (fT3), free thyroxine (fT4), reverse triiodothyronine (rT3) and thyrotropin (TSH) in serum, and fT3, fT4, rT3 and TSH levels in CSF of patients with brain tumor, and compared the results with control group. Study results indicated a statistically significantly higher level of rT3 in serum and CSF of brain tumor patients vs. control group (p<0.05). The rT3/fT3 ratio was highest in CSF and serum of brain tumor patients, yielding a statistically significant difference (p<0.05). These results could suggest higher permeability of the blood brain barrier in brain tumor patients. We also assume that rT3, in the framework of “cerebral low T3 syndrome”, is also generated through local intracerebral conversion. Disruption of this process in severe cerebral lesion can lead to increased rT3 concentrations, i.e. development of the “low T3 syndrome”.Cilj studije bio je doprinijeti boljem poznavanju cerebrospinalne tekućine kao vrijednog biološkog materijala u istraživanju moždanih tumora i “sindroma niskog T3”, te razmotriti ulogu hormona štitnjače unutar središnjega živčanog sustava kod bolesnika s ozbiljnim moždanim oštećenjem. Analizirali smo razinu ukupnog trijodtironina (tT3), ukupnog tiroksina (tT4), slobodnog trijodtironina (fT3), slobodnog tiroksina (fT4), reverznog trijodtironina (rT3) i tireotropina (TSH) u serumu i razinu fT3, fT4, rT3 i TSH u cerebrospinalnoj tekućini u bolesnika s tumorom mozga te dobivene rezultate usporedili s kontrolnom skupinom ispitanika. Rezultati su ukazali na statistički značajno veću razinu rT3 u serumu i cerebrospinalnoj tekućini u bolesnika s tumorom mozga u usporedbi s kontrolnom skupinom (p<0,05). Odnos rT3/fT3 bio je također statistički značajno veći kod bolesnika s tumorom mozga (p<0,05). Naše istraživanje moglo bi ukazivati na veću propustljivost krvno-moždane barijere u bolesnika s tumorom mozga. Također pretpostavljamo da se u bolesnika s tumorom mozga rT3 pojačano stvara kroz aktivniju intracerebralnu pretvorbu. Svakako, naši rezultati trebaju biti potvrđeni i daljnjim podrobnijim istraživanjima

Treatment of soft tissue infection and osteomyelitis with multi-drug resistant Acinetobacter baumannii following a tibial fracture surgery: case report

Cilj: Cilj je prikazati kirurško i antimikrobno liječenje komplicirane kirurške infekcije uzrokovane Acinetobacter baumannii. Prikaz slučaja: 57-godišnja pacijentica bila je premještena u našu ustanovu tri tjedna nakon osteosinteze proksimalnog multifragmentarnog prijeloma tibije s postoperacijskom infekcijom kosti i mekog tkiva uzrokovanom A. baumannii. Prema nalazu iz vanjske ustanove, osim na karbapeneme, fluorokinolone i aminoglikozide, soj je bio rezistentan i na sulbaktam i kolistin. U trenutku prijema pacijentica je bila febrilna, povišenih upalnih parametara i na terapiji ciprofloksacinom i rifampicinom. U našoj ustanovi ponovno su uzeti mikrobiološki uzorci iz kojih je bio izoliran multirezistentan A. baumannii, ali osjetljiv na sulbaktam i kolistin. Uz nekrektomiju mekog tkiva i sekvestrektomiju zahvaćenog dijela kosti te rekonstrukcijsko kirurško liječenje, provedena je i kombinirana terapija kolistinom i fosfomicinom tijekom 14 dana. Nakon 23 dana hospitalizacije pacijentica je dobrog općeg stanja i lokalnog nalaza otpuštena na fizikalnu terapiju. Zaključak: A. baumannii uzrokuje manje od 3% kirurških infekcija, a osobito su rizični bolesnici s prethodnim ozljedama kosti i mekog tkiva te prethodno provedenom antibiotskom terapijom. Kolistin je terapija izbora za liječenje infekcija uzrokovanih multirezistentnim A. baumannii. Iako je A. baumannii intrinzično rezistentan na fosfomicin, smatra se kako se u kombinaciji s kolistinom postiže sinergističko djelovanje. Budući da je fosfomicin mala molekula, dobro prodire i u biofilm. Kod naše pacijentice kombinacijom antimikrobne terapije i kirurškog liječenja postigao se odličan klinički ishod.Aim: The aim was to present surgical and antimicrobial treatment of complicated surgical site infection (SSI) caused by A. baumannii. Case report: 57-year-old female patient was admitted 3 weeks after plate osteosynthesis for proximal tibial multifragmented fracture. The surgery was performed in another institution. She presented with SSI and osteomyelitis due to A. baumannii. According to microbiology results from another institution, the strain was resistant to carbapenems, fluoroquinolones, aminoglycosides, and to sulbactam and colistin. At presentation she was already being treated with ciprofloxacin and rifampicin but was nevertheless febrile with elevated inflammation markers. New sets of microbiology samples were taken, and the cultures yielded a multi-drug resistant A. baumannii, although sensitive to sulbactam and colistin. In addition to soft tissue necrectomy and sequestrectomy of devitalized bone with subsequent reconstructive surgery, the patient was treated with 14-day long parenteral combination therapy – colistin and fosfomycin. After 23-day-long hospitalization, the patient was transferred to physical rehabilitation clinic in good general health and with satisfactory wound healing. Conclusion: Acinetobacter baumannii causes less than 3% of SSI-s, and patients with previous traumatic injuries and antibiotic therapy are most at risk. Colistin is preferred therapy for multi-drug resistant A. baumannii. Although A. baumannii is intrinsically resistant to fosfomycin, it is thought that combination therapy with colistin yields synergy. Since fosfomycin is a small molecule, it penetrates biofilm well. Due to extensive surgical and antimicrobial treatment, our patient had a good clinical outcome

Povezanost upalnih parametara i infekcija krvi uzrokovanih multirezistentnim Gram negativnim bakterijama kod COVID-19 pozitivnih bolesnika liječenih u jedinici intenzivnog liječenja – retrospektivna studija jednog centra

Objectives: During the COVID-19 pandemics we have seen in critically ill COVID-19 patients treated in the intensive care unit the parallel outbreak of multidrug resistant Gram-negative bacteria bloodstream infections, mainly Acinetobacter baumannii and Klebsiella pneumoniae. Methods: We conducted a retrospective cohort single-center study. The aim was to investigate the incidence, etiology and impact of intensive care unit bloodstream infections in COVID-19 patients admitted to the COVID-19 intensive care unit with a known burden of multidrug resistance and to evaluate the possibility that inflammatory parameters levels measured at two different time points of treatment can early predict multidrug resistant Gram-negative bacteria bloodstream infections and enable timely beginning of bacterial targeted antimicrobial therapy. Results: Our study confirmed that procalcitonin values of 2,46 mcg/L and neutrophil/lymphocyte ratio of 28,9 could be a reliable indicators for high risk stratification of multidrug resistant Gram-negative bacterial infection origin in critically ill COVID-19 patients (Mann Whitney U test, P=0,02). Conclusion: Monitoring dynamic shift of inflammatory parameters in critically ill COVID-19 patients could reliably help clinician to recognize the multidrug resistant Gram-negative bacteria bloodstream infections and start with the antimicrobial therapy in a timely manner.Cilj istraživanja: Tijekom COVID-19 pandemije uočili smo kod kritično bolesnih COVID-19 pozitivnih bolesnika liječenih na odjelu intenzivne njege paralelno izbijanje infekcija krvi uzrokovanih multirezistentnim Gram negativnim bakterijama, uglavnom Acinetobacter baumannii i Klebsiella pneumoniae. U praksi rezultati mikrobiološke potvrde infekcija krvi završeni su s određenom vremenskom odgodom. Stoga primarni cilj istraživanja bio je odrediti povezanost upalnih parametara (leukociti, limfociti, neutrofili, omjer neutrofila i limfocita, C-reaktivni protein, prokalcitonin) mjerenih u dvije različite vremenske točke (dan prijema u jedinicu intenzivnog liječenja i dan nastanka infekcija krvi potvrđenih pozitivnim hemokulturama) i nastanka infekcija krvi uzrokovanih multirezistentnim Gram negativnim. Sekundarni ciljevi istraživanja bili su istražiti učestalost, etiologiju i utjecaj infekcija krvi uzrokovanih multirezistentnim Gram negativnim bakterijama na ishod liječenja COVID-19 pozitivnih bolesnika. Materijali i metode: Proveli smo retrospektivno kohortno istraživanje u Kliničkoj bolnici Dubrava na intenzivističkom odjelu COVID-19 pozitivnih bolesnika u vremenskom period od 31. listopada 2020. godine do 31. ožujka 2021. godine. U istraživanju je sudjelovalo 166 COVID-19 pozitivnih bolesnika koji su zadovoljili kriterije uključenja u istraživanje. 122 COVID-19 bolesnika imali su mikrobiološki potvrđenu infekciju krvi uzrokovanu multirezistentnim Gram negativnim bakterijama. Kontrolna gupa imala je 44 COVID-19 bolesnika koji nisu razvili infekciju krvi. Svi podaci bolesnika skupljali su se iz povijesti bolesti i elektroničke baze podataka. Rezultati: Naša studija potvrdila je cut-off vrijednosti upalnih parametara prokalcitonina od 2,46 mcg/L i omjer neutrofila/limfocita od 28,9 kao pouzdane pokazatelje stratifikacije visoko rizičnih COVID-19 bolesnika za nastanak infekcije krvi uzrokovane multirezistentnim Gram negativnim bakterijama, Acinetobacter baumannii i Klebsiella pneumoniae (Mann Whitney U test, P=0,02). Zaključak: Dinamički monitoring upalnih parametara sa cut-off vrijednostima proklacitonina i omjera neutrofila i limfocita u različitim vremenskim intervalima u kritično bolesnih COVID-19 pozitivnih bolesnika pouzdani je pokazatelj visokog rizika nastanka infekcija krvi uzrokovanih multirezistentnim Gram negativnim bakterijama koji u kliničkoj praksi omogućuje pravovremeno uvođenje ciljane antimikrobne terapije prije dospijeća mikrobiološke potvrde

Campylobacter fetus Bacteremia Related to Vascular Prosthesis and Pseudoaneurysm Infection: A Case Report and Review

Background. Campylobacter fetus rarely causes gastrointestinal diseases but shows an affinity for the endovascular epithelium. Methods. We describe a case of C. fetus bacteremia related to vascular prosthesis and pseudoaneurysm infection, with a review of the literature. Results. A 67-year-old male was admitted with a history of fever, weakness and painful swelling of the groin. After unsuccessful treatment with ciprofloxacin, the patient was transferred to our hospital, where he had been previously treated for aortoiliac occlusive disease including a prosthetic aortobifemoral and popliteal bypass with polyester graft placement. An angiography showed a pseudoaneurysm in the groin and, therefore, repair of the pseudoaneurysm, removal of the prosthesis and biologic graft placement were performed. Blood cultures and tissue samples of the vascular prosthesis and pseudoaneurysm yielded C. fetus resistant to ciprofloxacin. The patient was treated with meropenem for four weeks, followed by amoxicillin-clavulanate for another two weeks after discharge. Eight previously published cases of C. fetus bacteremia due to infected cardiovascular prosthetic devices (prosthetic heart valves, implantable cardioverter-defibrillators and a permanent pacemaker) were summarized in the review. Conclusions. To our knowledge, this is the first report of a C. fetus bacteremia related to post-surgical infection of a vascular prosthesis causing a pseudoaneurysm

Tricuspid Valve Endocarditis Due to Methicillin-Resistant <i>Staphylococcus aureus</i> in a Previously Healthy Young Patient without a Drug Abuse History: A Case Report and a Review of the Literature

Right-sided infective endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) is strongly associated with intravenous drug abuse, congenital heart disease, or previous medical treatment and is rare in healthy patients without a history of drug abuse. Here, we present a case of an 18-year-old male with no drug abuse history and no medical burden who was diagnosed with MRSA tricuspid valve endocarditis. Due to initial symptoms which indicated community-acquired pneumonia and radiological finding of interstitial lesions, empiric therapy with ceftriaxone and azithromycin was started. After the detection of Gram-positive cocci in clusters in several blood culture sets, endocarditis was suspected, and flucloxacillin was added to the initial therapy. As soon as methicillin resistance was detected, the treatment was switched to vancomycin. Transesophageal echocardiography established the diagnosis of right-sided infective endocarditis. A toxicological analysis of hair was carried out, and no presence of narcotic drugs was found. After six weeks of therapy, the patient was fully recovered. Exceptionally, tricuspid valve endocarditis can be diagnosed in previously healthy people who are not drug addicts. As the clinical presentation commonly resembles a respiratory infection, a misdiagnosis is possible. Although MRSA rarely causes community-acquired infections in Europe, clinicians should be aware of this possibility

Infection as a predictor of mortality in decompensated liver cirrhosis: exploring the relationship to severity of liver failure

Background: Infections are common in patients with liver cirrhosis and increase mortality. We explored the relationship between infection and liver dysfunction in their effects on mortality. ----- Methods: Single-center data on decompensated liver cirrhosis patients hospitalized between March 2014 and December 2017 (index period) were reviewed until death, liver transplantation or 31 December 2018. Infections were classified as community-acquired infection (CAi) or hospital/healthcare associated infection (HCAi). Child-Pugh, model for the end-stage liver disease (MELD) and chronic liver failure-organ failure (CLiF-OF) scores indicated liver (dys)function. ----- Results: We enrolled 155 patients (85% alcoholic liver disease), 65 without infection at first hospitalization, 48 with CAi and 42 with HCAi. Multidrug resistant agents were confirmed in 2/48 (4.2%) CAi and 10/42 (23.8%) HCAi patients. At first hospitalization, infection was independently associated with worse liver dysfunction and vice versa, and with higher 30-day mortality [odds ratio (OR) = 2.73, 95% confidence interval (CI) 1.07-6.94]. The association was reduced with adjustment for MELD/CLiF-OF scores, but mediation analysis detected an indirect (via liver dysfunction) association. Twenty-eight patients were repeatedly hospitalized, 11 with new HCAi. HCAi was independently associated with twice higher risk of medium-term mortality and added an additional risk to any level of liver dysfunction, considering all or patients who survived the first 30 days. In those repeatedly hospitalized, HCAi appeared independently associated with a higher probability of infection and higher MELD scores at subsequent hospitalizations. ----- Conclusion: Infection (particularly HCAi) adds mortality risk to any level of liver dysfunction in decompensated liver cirrhosis patients. Mechanisms of long(er)-term effects (in acute episode survivors) seemingly include enhanced deterioration of liver function

Healthcare-Associated Bloodstream Infections Due to Multidrug-Resistant Acinetobacter baumannii in COVID-19 Intensive Care Unit: A Single-Center Retrospective Study

Healthcare-associated infections are an emerging cause of morbidity and mortality in COVID-19 intensive care units (ICUs) worldwide, especially those caused by multidrug-resistant (MDR) pathogens. The objectives of this study were to assess the incidence of bloodstream infections (BSIs) among critically ill COVID-19 patients and to analyze the characteristics of healthcare-associated BSIs due to MDR Acinetobacter baumannii in an COVID-19 ICU. A single-center retrospective study was conducted at a tertiary hospital during a 5-month period. The detection of carbapenemase genes was performed by PCR and genetic relatedness by pulsed-field gel electrophoresis (PFGE) and multilocus-sequence typing. A total of 193 episodes were registered in 176 COVID-19 ICU patients, with an incidence of 25/1000 patient-days at risk. A. baumannii was the most common etiological agent (40.3%), with a resistance to carbapenems of 100%. The blaOXA-23 gene was detected in ST2 isolates while the blaOXA-24 was ST636-specific. PFGE revealed a homogeneous genetic background of the isolates. The clonal spread of OXA-23-positive A. baumannii is responsible for the high prevalence of MDR A. baumannii BSIs in our COVID-19 ICU. Further surveillance of resistance trends and mechanisms is needed along with changes in behavior to improve the implementation of infection control and the rational use of antibiotics

Outbreak of healthcare-associated bacteremia caused by Burkholderia gladioli due to contaminated multidose vials with saline solutions in three Croatian hospitals

Objectives: Burkholderia gladioli has been associated with infections in patients with cystic fibrosis, chronic granulomatous disease, and other immunocompromising conditions. The aim of this study was to better depict the outbreak of healthcare-associated bacteremia caused by B. gladioli due to exposure to contaminated multidose vials with saline solutions. ----- Methods: An environmental and epidemiologic investigation was conducted by the Infection Prevention and Control Team (IPCT) to identify the source of the outbreak in three Croatian hospitals. ----- Results: During a 3-month period, 13 B. gladioli bacteremia episodes were identified in 10 patients in three Croatian hospitals. At the time of the outbreak, all three hospitals used saline products from the same manufacturer. Two 100-ml multidose vials with saline solutions and needleless dispensing pins were positive for B. gladioli. All 13 bacteremia isolates and two isolates from the saline showed the same antimicrobial susceptibility patterns and pulsed-field gel electrophoresis profile, demonstrating clonal relatedness. ----- Conclusion: When an environmental pathogen causes an outbreak, contamination of intravenous products must be considered. Close communication between the local IPCT and the National Hospital Infection Control Advisory Committee is essential to conduct a prompt and thorough investigation and find the source of the outbreak