Porcine Bioprosthetic Aortic Valve Endocarditis with Ring Abscess and Aortic Stenosis

Porcine bioprosthetic valve endocarditis is an infrequent but serious complication of valve replacement surgery. Ring (or annular) abscess is a frequent finding in mechanical valve endocarditis. In contrast, porcine valve endocarditis most often involves the cusps, and annular infection is uncommon. Porcine valvular dysfunction secondary to endocarditis usually takes the form of incompetence, whereas stenosis is less frequent. We report a case of a 76-year-old female who developed endocarditis wilh Staphylococcus epidermidis nine months after placement of a Carpenter-Edwards porcine aortic valve. Her initial presentation included complete heart block and moderate aortic stenosis. Transesophageal echocardiography aided the diagnosis by demonstrating large vegetations, while transthoracic echocardiography showed only slight thickening of the valve leaflets. At operation, there was a circumferential abscess around the sewing ring causing valve dehiscence and virtual discontinuity of the aorta from the left ventricle. Valve degeneration and organisms within the cusps were observed on microscopy. This case illustrates two infrequent complications of porcine aortic valve endocarditis, namely massive annular abscess with invasion of the conducting system and aortic stenosis. It also demonstrates the utility and limitations of transesophageal echocardiography in the diagnosis of this disorder

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

An Overview of the Newer Antibiotics

The introduction of a large number of new antibiotics has made selecting the one most appropriate for treatment a confusing task for the practicing physician. One problem is that the differences in pharmacokinetics, in vitro activity, and clinical indications between some of these agents may be relatively minor; this is especially true of the new cephalosporins. Another problem is that the generic names of the cephalosporins are so similar that it is impractical, even for the infectious diseases specialist, to be familiar with all of them. This review attempts to summarize the most important characteristics of these new antibiotics and emphasizes their indications in clinical practice

Infectious Complications in Renal Transplant Recipients

Post-kidney transplant infection is the most common life-threatening complication of long-term immunosuppressive therapy. Optimal immunosuppression, in which a balance is maintained between prevention of rejection and avoidance of infection, is the most challenging aspect of posttransplantation care. The study of infectious complications in immunologically compromised recipients is changing rapidly, particularly in the fields of prophylactic and preemptive strategies, molecular diagnostic methods, and antimicrobial agents. In addition, emerging pathogens such as BK polyomavirus and West Nile flavivirus infections and the introduction of newer immunosuppressive agents that constantly change the risk profiles for opportunistic infections has added layers of complexity to this burgeoning field. Although remarkable progress has been made in these disciplines, comprehensive understanding of the clinical manifestations of infections remains limited, and the standardization of prophylaxis, diagnosis, and treatment of most infections is yet inadequately defined. The long-term goal for optimal care of transplant recipients, with respect to infection, is the prevention and/or early recognition and treatment of infections while avoiding drug-related toxicities. © 2006 National Kidney Foundation, Inc

Susceptibility at high inoculum of penicillin-resistant Staphylococcus aureus to six cephalosporins

Six cephalosporins (currently available for clinical use or undergoing clinical trials) were tested by tube dilution method against high inoculum (107 colony forming units) of 37 strains of penicillin resistant Staphylococcus aureus. 3.1 μg/ml of cephalothin inhibited 100% of strains while higher concentrations of cefoxitin, cephapirin, cefamandole, cephalexin and cephradine were required. The percent of strains with minimal inhibitory concentration higher than 3.1 μg/ml ranged between 10.8% (cefoxitin) and 100% (cephradine). These findings support the observation that cephalothin is less susceptible to inactivation than the other cephalosporins. Although the exact clinical implication of these findings has not been established, cephalothin might be the cephalosporin of choice for treatment of severe infections caused by penicillin resistant Staphylococcus aureus

Risk factors for single and recurrent symptomatic urinary tract infections within the first year after kidney transplantation

Urinary Tract Infection (UTI) is the most common infection after kidney transplantation (KT). However studies have been incongruent regarding risk factors associated with incidence and recurrence of symptomatic UTIs in this population. We identified patients who underwent KT between 01/2012 to 12/2013 and developed symptomatic single or recurrent UTI within the first year of transplant. Recurrent infection was defined as having at least 2 UTIs in 6 months or 3 UTIs in one year. Demographic information, medical comorbidities and transplant variables were assessed for association with single and recurrent UTIs. 190 patients underwent KT during the study period. After excluding asymptomatic bacteriuria, a total of 36 patients developed a UTI within the first year of which 18 had recurrent UTIs. Factors associated with developing UTI (single or recurrent) were female gender∗ and repeat KT∗. Patients with recurrent UTIs (vs. single) were significantly more likely to be diabetics∗ , to have higher comorbidity index∗. KT recipients with recurrent UTI had significantly higher incidence of adverse renal outcomes, defined as increase in serum creatinine by 50% during the first year of transplant∗. Interestingly there was a significant association between isolation of Klebsiella pneumoniae in the index urine culture and the likelihood of recurrent UTI ∗. UTI is a frequent problem after KT and has high likelihood of recurrence. Multiple demographic, transplant and microbiological factors interplay as significant predisposing factors. (Table Presented)

Clinical characteristics and outcomes of COVID-19 in solid organ transplant recipients: A case-control study

Solid organ transplant recipients (SOTr) with coronavirus disease 2019 (COVID-19) are expected to have poorer outcomes compared to nontransplant patients because of immunosuppression and comorbidities. The clinical characteristics of 47 SOTr (38 kidneys and 9 nonkidney organs) were compared to 100 consecutive hospitalized nontransplant controls. Twelve of 47 SOTr managed as outpatients were subsequently excluded from the outcome analyses to avoid potential selection bias. Chronic kidney disease (89% vs 57% P = .0007), diabetes (66% vs 33% P = .0007), and hypertension (94% vs 72% P = .006) were more common in the 35 hospitalized SOTr compared to controls. Diarrhea (54% vs 17%, P \u3c .0001) was more frequent in SOTr. Primary composite outcome (escalation to intensive care unit, mechanical ventilation, or in-hospital all-cause mortality) was comparable between SOTr and controls (40% vs 48%, odds ratio [OR] 0.72 confidence interval [CI] [0.33-1.58] P = .42), despite more comorbidities in SOTr. Acute kidney injury requiring renal replacement therapy occurred in 20% of SOTr compared to 4% of controls (OR 6 CI [1.64-22] P = .007). Multivariate analysis demonstrated that increasing age and clinical severity were associated with mortality. Transplant status itself was not associated with mortality