An Automated Surveillance Strategy to Identify Infectious Complications After Cardiac Implantable Electronic Device Procedures.

Background.  The optimum approach for infectious complication surveillance for cardiac implantable electronic device (CIED) procedures is unclear. We created an automated surveillance tool for infectious complications after CIED procedures. Methods.  Adults having CIED procedures between January 1, 2005 and December 31, 2011 at Duke University Hospital were identified retrospectively using International Classification of Diseases, 9th revision (ICD-9) procedure codes. Potential infections were identified with combinations of ICD-9 diagnosis codes and microbiology data for 365 days postprocedure. All microbiology-identified and a subset of ICD-9 code-identified possible cases, as well as a subset of procedures without microbiology or ICD-9 codes, were reviewed. Test performance characteristics for specific queries were calculated. Results.  Overall, 6097 patients had 7137 procedures. Of these, 1686 procedures with potential infectious complications were identified: 174 by both ICD-9 code and microbiology, 14 only by microbiology, and 1498 only by ICD-9 criteria. We reviewed 558 potential cases, including all 188 microbiology-identified cases, 250 randomly selected ICD-9 cases, and 120 with neither. Overall, 65 unique infections were identified, including 5 of 250 reviewed cases identified only by ICD-9 codes. Queries that included microbiology data and ICD-9 code 996.61 had good overall test performance, with sensitivities of approximately 90% and specificities of approximately 80%. Queries with ICD-9 codes alone had poor specificity. Extrapolation of reviewed infectious rates to nonreviewed cases yields an estimated rate of infection of 1.3%. Conclusions.  Electronic queries with combinations of ICD-9 codes and microbiologic data can be created and have good test performance characteristics for identifying likely infectious complications of CIED procedures.

A randomized clinical trial of high volume peritoneal dialysis versus extended daily hemodialysis for acute kidney injury patients

Background: Acute kidney injury (AKI) requiring dialysis in critically ill patients is associated with an in-hospital mortality rate of 50-80 %. Extended daily hemodialysis (EHD) and high volume peritoneal dialysis (HVPD) have emerged as alternative modalities. Methods: A double-center, randomized, controlled trial was conducted comparing EHD versus HVPD for the treatment for AKI in the intensive care unit (ICU). Four hundred and seven patients were randomized and 143 patients were analyzed. Principal outcome measure was hospital mortality, and secondary end points were recovery of renal function and metabolic and fluid control. Results: There was no difference between the two groups in relation to median ICU stay [11 (5.7-20) vs. 9 (5.7-19)], recovery of kidney function (26.9 vs. 29.6 %, p = 0.11), need for chronic dialysis (9.7 vs. 6.5 %, p = 0.23), and hospital mortality (63.4 vs. 63.9 %, p = 0.94). The groups were different in metabolic and fluid control. Blood urea nitrogen (BUN), creatinine, and bicarbonate levels were stabilized faster in EHD group than in HVPD group. Delivered Kt/V and ultrafiltration were higher in EHD group. Despite randomization, there were significant differences between the groups in some covariates, including age, pre-dialysis BUN, and creatinine levels, biased in favor of the EHD. Using logistic regression to adjust for the imbalances in group assignment, the odds of death associated with HVPD was 1.4 (95 % CI 0.7-2.4, p = 0.19). A detailed investigation of the randomization process failed to explain the marked differences in patient assignment. Conclusions: Despite faster metabolic control and higher dialysis dose and ultrafiltration with EHD, this study provides no evidence of a survival benefit of EHD compared with HVPD. The limitations of this study were that the results were not presented according to the intention to treat and it did not control other supportive management strategies as nutrition support and timing of dialysis initiation that might influence outcomes in AKI. © 2012 Springer Science+Business Media Dordrecht.

Different outcomes of peritoneal catheter percutaneous placement by nephrologists using a trocar versus the Seldinger technique: the experience of two Brazilian centers

A good catheter implantation technique is important to allow effective peritoneal access function and long-term technique survival. Studies regarding results obtained by nephrologists in comparison with different techniques have been limited. The aim of this study was to investigate the rate of early catheter-related complications and catheter survival in two Brazilian centers, according to two different percutaneous methods of catheter implantation performed by nephrologist team. Adult incident patients recruited from January 2006 to July 2013 having undergone first peritoneal dialysis (PD) catheter implantation were included in the analysis. Mechanical and infectious early complication rates were defined as time to the first event occurring up to 3 months. Four hundred and forty-five consecutive Tenckhoff catheters were implanted by nephrologist team percutaneously after antibiotic prophylaxis in an operating room: trocar was used in 349 (78.4 %) and Seldinger technique (ST) in 99 (21.6 %). The ST was significantly associated with a lower rate of leak (16.3 vs 3 %, p = 0.03) and outflow failure due to tip catheter migration (22.6 vs 10.1 %, p = 0.04), while early infectious complication rates were similar between the two groups (p = 0.59). Long-term catheter survival was higher in Seldinger group (log-rank, p = 0.031). By Cox multivariate analysis, adjusted for age, sex, and diabetes, the ST remained independently associated with better catheter survival [HR 0.681 (0.462-0.910), p = 0.04]. As conclusion, our experience showed better PD outcomes with the ST than trocar method of catheter implantation by nephrologist.

Corticosteroids and peritonsillar abscess formation in infectious mononucleosis

Peritonsillar abscess formation is an uncommon complication of infectious mononucleosis (IM). Early case reports implicated corticosteroids in the development of such abscesses, however, subsequent studies suggested that these drugs do not promote the formation of abscesses at several sites outside the central nervous system. It has recently been demonstrated that zwitterionic polysaccharides, in bacterial capsules, form complexes with CD4(+) T lymphocytes leading to abscess formation. A patient is presented who developed peritonsillar abscess a few days after initiation of corticosteroid therapy for IM; the medical literature was reviewed in respect of this subject. It appears that the occurrence of these abscesses in IM is not strongly linked to corticosteroid treatment. The authors, therefore, recommend that steroids should not be withheld from patients with severe IM on the basis that they may precipitate the development of peritonsillar abscess.

Peridontal disease : the overlooked diabetes complication

Periodontal diseases are infectious processes that occur in the presence of bacteria, which trigger an inflammatory response. Periodontal disease is associated with many medical conditions, including diabetes mellitus and its complications (such as kidney disease). It has been described as the "sixth diabetes complication" but is often overlooked in routine diabetes management and complication screening processes. Proactive, preventative dental and diabetes self care, as well as regular dental and diabetes assessment, are important management strategies because periodontal disease contributes to the progression of impaired glucose tolerance to diabetes mellitus and to hyperglycemia in individuals with established diabetes.

Endophthalmitis: A Rare but Devastating Metastatic Bacterial Complication of Hemodialysis Catheter-Related Sepsis

There are many infectious complications related to vascular access in patients undergoing maintenance hemodialysis. We report two cases of endophthalmitis as a metastatic infection associated with a tunneled catheter and a temporary dual lumen catheter. Both patients were diabetic. A 61-year-old female on maintenance hemodialysis by a jugular tunnelized catheter during the past year was receiving parenteral antibiotics for catheter salvage due to fever episodes in the last 3 months. She was admitted to the hospital presenting pain, proptosis, conjunctival hyperemia, corneal infiltrate, and visual acuity of no light perception (NLP). A 51-year-old male recently undergoing hemodialysis by a temporary dual lumen catheter presented fever. His catheter was removed, but he was admitted to the hospital presenting fever, decreased vision, edema, and pain in his left eye. On examination, eyelid edema, conjunctival hyperemia, purulent secretion, hypopyon in the pupils, and visual acuity of NLP were verified. A diagnosis of endogenous endophthalmitis was made in both patients on clinical grounds and computed tomography. Evisceration of the left eye was the first option of treatment for both patients due to poor vision. Cultures of the eviscerated ocular globes showed Staphylococcus hemolyticus and Staphylococcus aureus, respectively. After evisceration, both patients received treatment, had a good outcome, and were discharged to continue their hemodialysis program. Metastatic bacterial endophthalmitis is a rare complication of dialysis catheter-related bacteremia. When suspected, urgent ophthalmologic evaluation and treatment are needed to reduce the risk of losing vision in the affected eye.

Outpatient Parenteral Antimicrobial Therapy Practices among Adult Infectious Disease Physicians

Objective. To identify current outpatient parenteral antibiotic therapy practice patterns and complications. Methods. We administered an 11-question survey to adult infectious disease physicians participating in the Emerging Infections Network (EIN), a Centers for Disease Control and Prevention-sponsored sentinel event surveillance network in North America. The survey was distributed electronically or via facsimile in November and December 2012. Respondent demographic characteristics were obtained from EIN enrollment data. Results. Overall, 555 (44.6%) of EIN members responded to the survey, with 450 (81%) indicating that they treated 1 or more patients with outpatient parenteral antimicrobial therapy (OPAT) during an average month. Infectious diseases consultation was reported to be required for a patient to be discharged with OPAT by 99 respondents (22%). Inpatient (282 [63%] of 449) and outpatient (232 [52%] of 449) infectious diseases physicians were frequently identified as being responsible for monitoring laboratory results. Only 26% (118 of 448) had dedicated OPAT teams at their clinical site. Few infectious diseases physicians have systems to track errors, adverse events, or "near misses" associated with OPAT (97 [22%] of 449). OPAT-associated complications were perceived to be rare. Among respondents, 80% reported line occlusion or clotting as the most common complication (occurring in 6% of patients or more), followed by nephrotoxicity and rash (each reported by 61%). Weekly laboratory monitoring of patients who received vancomycin was reported by 77% of respondents (343 of 445), whereas 19% of respondents (84 of 445) reported twice weekly laboratory monitoring for these patients. Conclusions. Although use of OPAT is common, there is significant variation in practice patterns. More uniform OPAT practices may enhance patient safety.

Thrombophlebitis of the temporal vein as an extracranial complication of acute bacterial rhinosinusitis

A 39-year-old white man presented with a swollen left upper eyelid secondary to progressive acute bacterial rhinosinusitis (ABRS). Physical examination found a 40% reduction in vision in the left eye and right-sided erythematous temporal swelling with tenderness to palpation. Computed tomography revealed the presence of an inflammatory lesion in the left orbit. Duplex ultrasonography demonstrated a thrombotic occlusion in the right superficial temporal vein (STV). For treatment of the complicated ARBS, the patient received intravenous antibiotics and underwent surgery. The STV thrombophlebitis was treated with low-molecular-weight heparin. Postoperatively, the patient recovered completely and his vision normalized; 10 days later, duplex ultrasonography showed a patent STV. The development of contralateral STV thrombophlebitis is conceivably facilitated by venous anastomoses of the scalp in the front of the head. As a result, embolic spread would be a possible complication of infectious ABRS foci communicating with intraorbital and pericranial veins. To the best of our knowledge, this is the first reported case of such a complication of ARBS in the literature.

Paramedic knowledge of infectious disease aetiology and transmission in an Australian Emergency Medical System

Introduction: Paramedics and other emergency health workers are exposed to infectious disease particularly when undertaking exposure-prone procedures as a component of their everyday practice. This study examined paramedic knowledge of infectious disease aetiology and transmission in the pre-hospital care environment.--------- Methods: A mail survey of paramedics from an Australian ambulance service (n=2274) was conducted.--------- Results: With a response rate of 55.3% (1258/2274), the study demonstrated that paramedic knowledge of infectious disease aetiology and modes of transmission was poor. Of the 25 infectious diseases included in the survey, only three aetiological agents were correctly identified by at least 80% of respondents. The most accurate responses for aetiology of individual infectious diseases were for HIV/AIDS (91.4%), influenza (87.4%), and hepatitis B (85.7%). Poorest results were observed for pertussis, infectious mononucleosis, leprosy, dengue fever, Japanese B encephalitis and vancomycin resistant enterococcus (VRE), all with less than half the sample providing a correct response. Modes of transmission of significant infectious diseases were also assessed. Most accurate responses were found for HIV/AIDS (85.8%), salmonella (81.9%) and influenza (80.1%). Poorest results were observed for infectious mononucleosis, diphtheria, shigella, Japanese B encephalitis, vancomycin resistant enterococcus, meningococcal meningitis, rubella and infectious mononucleosis, with less than a third of the sample providing a correct response.--------- Conclusions: Results suggest that knowledge of aetiology and transmission of infectious disease is generally poor amongst paramedics. A comprehensive in-service education infection control programs for paramedics with emphasis on infectious disease aetiology and transmission is recommended.

The Metapopulation Dynamics of an Infectious Disease: Tuberculosis in Possums

An SEI metapopulation model is developed for the spread of an infectious agent by migration. The model portrays two age classes on a number of patches connected by migration routes which are used as host animals mature. A feature of this model is that the basic reproduction ratio may be computed directly, using a scheme that separates topography, demography, and epidemiology. We also provide formulas for individual patch basic reproduction numbers and discuss their connection with the basic reproduction ratio for the system. The model is applied to the problem of spatial spread of bovine tuberculosis in a possum population. The temporal dynamics of infection are investigated for some generic networks of migration links, and the basic reproduction ratio is computed—its value is not greatly different from that for a homogeneous model. Three scenarios are considered for the control of bovine tuberculosis in possums where the spatial aspect is shown to be crucial for the design of disease management operations