The impact of nasal carriage of methicillin-resistant and methicillin-susceptible Staphylococcus a ureus (MRSA & MSSA) on vascular access-related septicemia among patients with type-II diabetes on dialysis

BACKGROUND: Fairly higher nasal carriage rates among type-II diabetics place them at a greater risk of endogenous Staphylococcus aureus linked vascular access-related septicemia (VRS) that is also dependent on the type of vascular access used for hemodialysis (HD). The prevalence of nasal carriage of methicillin susceptible and methicillin-resistant S. aureus (MSSA and MRSA) and its impact on VRS was determined in order to identify most vulnerable group and plan potential prophylactic strategies, accordingly. METHODS: Five standardized nasal swab cultures were performed in 208 patients enrolled for long-term HD through July 1996 to July 1999. Persistent nasal carriage was defined by two or more positive cultures for MSSA or MRSA. Peripheral blood cultures were collected on clinical suspicion of septicemia. RESULTS: The prevalence of type-II diabetes of 28.0% with 72.4% of nasal carriage rate and three folds higher S. aureus related VRS (RR-3.19, p<0.0001) than diabetic non-carriers on HD, was observed. Type-II diabetics also had higher MSSA and MRSA nasal carriage rates (53.4% and 19.0%) than non-diabetic nasal carriers (18.6 and 6.0%) yet, carried a comparable (RR-4.0 vs. 4.5) risk of VRS between MSSA and MRSA nasal carriers. Among diabetic type-II S. aureus nasal carriers, central venous catheters (CVCs) carried 35 and 38 times higher collective risk of developing MSSA and MRSA nasal carriage-related VRS respectively than Arterio-venous fistula (AVF). The AVF recorded the lowest risk of developing MSSA and MRSA nasal carriage-related VRS (0.013 and 0.010 episodes/patient-year) in both diabetic type-II MSSA and MRSA nasal carrier groups. CONCLUSIONS: Diabetic type-II S. aureus nasal carriers on HD through CVCs make an extremely high-risk group for MSSA and MRSA nasal carriage-related VRS. The incidence of S. aureus nasal carriage-related VRS could reasonably be reduced through a challenging obligation of optimizing AVF prevalence in this high-risk group, while limiting the use of CVCs, at the same time.     

Lack of efficacy of mupirocin in the prevention of infections with Staphylococcus aureus in liver transplant recipients and candidates

BACKGROUND: Infections with Staphylococcus aureus are a significant problem in patients in liver transplant units. An association between prior nasal carriage with and subsequent infections has been documented previously in liver transplant recipients and patients with cirrhosis. However, the role of decolonization with mupirocin applied intranasally for the prevention of S. aureus infections in these patients has not been determined. METHODS: S. aureus nasal carriage was prospectively sought in 70 consecutive liver transplant candidates. Mupirocin two times per day for 5 days was administered to the carriers. Follow-up nasal cultures to document decolonization were performed 5 days after the final application of mupirocin. The primary endpoint was the development of S. aureus infections. RESULTS: Thirty-one of 70 patients (44%) were found to be nasal carriers and 27 of 31 nasal carriers (87%) were successfully decolonized. However, 12 of 27 patients (37%) successfully decolonized became recolonized with S. aureus, and an additional nine patients who were initially noncarriers became newly colonized with S. aureus during the study period. Despite the use of mupirocin, 16 of 70 patients (23%) developed an infection with S. aureus. No isolate was found to be mupirocin resistant. CONCLUSION: Elimination of S. aureus nasal carriage by mupirocin did not prevent S. aureus infections in patients in our liver transplant unit.     

Outcomes of Colonization with MRSA and VRE Among Liver Transplant Candidates and Recipients

Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) infections cause significant morbidity and mortality among liver transplant candidates and recipients. To assess rates of MRSA and VRE colonization, we obtained active surveillance cultures from 706 liver transplant candidates and recipients within 24 h of admission to an 11-bed liver transplant ICU from October 2000 to December 2005. Patients were followed prospectively to determine the cumulative risk of MRSA or VRE infection or death by colonization status. Outcomes were assessed by Kaplan–Meier survival analysis and Cox regression and multivariate logistic regression adjusting for covariates. The prevalence of newly detected MRSA nasal and VRE rectal colonization was 6.7% and 14.6%, respectively. Liver transplant candidates and recipients with MRSA colonization had an increased risk of MRSA infection (adjusted OR = 15.64, 95% CI 6.63–36.89) but not of death (adjusted OR = 1.00, 95% CI 0.43–2.30), whereas those with VRE colonization had an increased risk both of VRE infection (adjusted OR = 3.61, 95% CI 2.01–6.47) and of death (adjusted OR = 2.12, 95% CI 1.27–3.54) compared with noncolonized patients. Prevention and control strategies, including use of active surveillance cultures, should be implemented to reduce the rates of both MRSA and VRE colonization in this high-risk patient population.     

Nasal Carriage of Methicillin-Resistant Staphylococcus aureus in Vascular Surgery

The purpose of this study was to determine the prevalence of nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) and to define risk factors allowing identification of high-risk patients for MRSA nasal carriage at admission to the vascular surgery unit. From March 23, 2004 to July 13, 2004, screening for nasal carriage of MRSA was conducted at admission to the vascular surgery unit and 1 week thereafter. To analyze risk factors for MRSA nasal carriage at admission to the vascular surgery unit, a case-control study was carried out in patients presenting colonization at the time of admission. A total of 308 patients underwent nasal screening for MRSA. Thirteen were colonized with MRSA (nine at admission and four acquired), i.e., 4.2% of patients. Methicillin-susceptible Staphylococcus aureus (MSSA) was found in 11.4% of patients who underwent screening. Six patients with MRSA infection were identified during the study period. The two patients who acquired infection were colonized at the time of admission. Arrival from another health-care facility and from another department was a significant risk factor for carriage of MRSA. The prevalence of nasal carriage in vascular surgery was 4.2%. Nasal screening is highly cost-effective since 60% of MRSA carriers were undetected using diagnostic specimens alone. French recommendations issued for cardiac and orthopedic surgery by the consensus conference on preoperative management of infectious risk on March 5, 2004, should be extended to vascular surgery.     

Hepatic iron content and the risk of Staphylococcus aureus bacteremia in liver transplant recipients

Iron is a critical nutrient source and contributes to staphylococcal pathogenesis. We assessed the role of hepatic explant iron overload as a risk factor for Staphylococcus aureus bacteremia in liver transplant recipients. Seven of 13 cases with S aureus bacteremia (53.8%) had hepatic explant iron concentrations that exceeded normal limits (grade > or = 2). Length of posttransplant intensive care unit stay (P= .013) and hepatocellular carcinoma as underlying liver disease (P = .04), but not hepatic explant iron concentration, correlated with a higher risk of S aureus bacteremia after transplantation. However, noncarriers (patients without S aureus nasal carriage) who developed S aureus bacteremia were more likely to have high hepatic iron content; 4 of 7 (57%) noncarriers with high-grade iron content developed S aureus bacteremia but no noncarriers with low-grade iron content did (P = .07). All noncarriers who became infected had high iron content (grade > or = 2) of the hepatic explant. A readily quantifiable assessment of hepatic iron at the time of transplantation can potentially identify patients without carriage who may be at risk for early S aureus bacteremia.     

Colonization with methicillin-resistant Staphylococcus aureus after liver transplantation.

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of infection after orthotopic liver transplantation (OLT). Colonization with MRSA is associated with a higher risk of infection. Previous studies have shown a high prevalence of MRSA colonization among OLT candidates. However, the risk of colonization with MRSA after OLT is still unclear. The objective of this study was to estimate the incidence and the factors associated with colonization with MRSA after OLT. This was a prospective cohort study including patients submitted to OLT between the years 2000 and 2002. Surveillance cultures of nasal swab specimens were performed within the 1st 72 hours of hospital admission and, subsequently, on weeks 2, 6, 13, and 26. Patients whose baseline cultures revealed nasal carriage of MRSA were excluded. A total of 60 patients were included in the study. The median follow-up was 72 days. A total of 9 patients (15%) became colonized. In multiple logistic regression analyses, the use of a urinary catheter for > or =5 days (P = .006), postoperative bleeding at the surgical site (P = .009), and preoperative use of fluoroquinolones (P = .08) were associated with a higher risk of colonization. Patients without any of these risk factors did not become colonized. In conclusion, nasal carriage of MRSA is frequently acquired after OLT. Periodic postoperative screening for MRSA carriage should be an integral component in programs designed to reduce nosocomial MRSA transmission in these patients. Further studies are needed to set up and validate a predictive model that could allow targeting postoperative screening to high-risk OLT recipients.     

Preoperative carriage and postoperative same-species sternal wound infection after cardiac surgery

Sternal wound infection (SWI) after cardiac surgery remains an important problem. Prediction of pathogens involved in such infection could guide antibiotics. From April 1, 2006 to December 31, 2008, retrospectively, we evaluated the diagnostic value of preoperative methicillin-sensible Staphylococcus aureus (MSSA), methicillin-resistant S. aureus (MRSA) or multi-drug resistant Gram-negative bacillus (MDRGNB) carriage to predict same-pathogens involved in postoperative SWI. All patients referred for elective cardiac surgery were screened using multisite (nares, axillae, rectal) sampling at admission to detect MSSA, MRSA, and MDRGNB. Of the 1895 patients addressed, 425 patients (22.4%) were colonized at admission. Preoperative carriers more frequently developed SWI than non-carriers, respectively, 11% vs. 5.5% (P<0.05). Because of the small sample, MDRGNB carriers could not be analyzed. For prediction of MSSA SWI with preoperative MSSA carriage, the area under the receiver operating characteristic (ROC) curve was 0.720 (95% confidence interval (CI), 0.364-0.796) and 0.710 (95% CI, 0.623-0.787) for prediction of MRSA SWI with preoperative MRSA carriage. Preoperative MSSA carriage is frequent but preoperative MRSA or MDRGNB carriage remains infrequent. The ability of preoperative carriage to predict a same-pathogen-postoperative SWI was low and should not be used to guide empirical antibiotherapy.     

Methicillin-resistant Staphylococcus aureus carriage, infection and transmission in dialysis patients, healthcare workers and their family members.

BACKGROUND: Carriage and subsequent infection with methicillin resistant S. aureus (MRSA) and its transmission between hospital and community settings have not been studied in dialysis patients and their contacts. METHODS: Surveillance for nasal MRSA carriage and infection among dialysis patients, healthcare workers (HCWs) and their family members in a dialysis centre was prospectively undertaken during three time periods within 1 year. Molecular typing was used to determine epidemiological relationship. RESULTS: Among 1687 samples collected, MRSA colonization rates were 2.41% (2/83) for peritoneal dialysis patients and 2.36% (12/509) for haemodialysis patients. Five (5/14) subjects subsequently had MRSA infection. The clinical MRSA isolates had the same molecular type as the colonized strains of the same person, indicating MRSA colonization preceded clinical infection. Significantly higher MRSA nasal carriage rates were observed among family members of HCWs than family members of dialysis patients (P = 0.0024). Only three major clones were observed. Pulmonary diseases (OR: 4.873, 95% CI: 1.668-14.235), recent admission to a hospital (OR: 2.797, 95% CI: 1.291-6.059) and recent antibiotics usage (OR: 2.319, 95% CI: 1.053-5.104) were also significantly associated with MRSA carriage. CONCLUSION: Transmission of MRSA among dialysis patients, HCWs and their family members in a dialysis unit could be inferred. Monitoring and eradication of MRSA from patients, HCWs and their family members should be considered to prevent continuous spread between healthcare facilities and the community.     

Cefotaxime-heparin lock prophylaxis against hemodialysis catheter-related sepsis among Staphylococcus aureus nasal carriers

Staphylococcus aureus nasal carriers undergoing hemodialysis (HD) through tunneled cuffed catheters (TCCs) form a high-risk group for the development of catheter-related bloodstream infections (CRBSI) and ensuing morbidity. The efficacy of antibiotic-locks on the outcomes of TCCs among S. aureus nasal carriers has not been studied earlier. Persistent nasal carriage was defined by two or more positive cultures for methicillin-susceptible (MSSA) or methicillin-resistant (MRSA) S. aureus of five standardized nasal swabs taken from all the participants dialyzed at a large out-patient HD center affiliated to a tertiary care hospital. Of 218 participants, 82 S. aureus nasal carriers dialyzed through TCCs (n = 88) were identified through April 2005 to March 2006 and randomized to two groups. Group I comprised of 39 nasal carriers who had TCCs (n = 41) "locked" with cefotaxime/heparin while group II included 43 patients with TCCs (n = 47) filled with standard heparin. The CRBSI incidence and TCC survival at 365 days were statistically compared between the two groups. A significantly lower CRBSI incidence (1.47 vs. 3.44/1000 catheter-days, P <0.001) and higher infection-free TCC survival rates at 365 days (80.5 vs. 40.4%, P <0.0001) were observed in the cefotaxime group compared with the standard heparin group. However, no significant difference in MRSA-associated CRBSI incidence was observed between the two groups. Cefotaxime-heparin "locks" effectively reduced CRBSI-incidence associated with gram-positive cocci, including MSSA, among S. aureus nasal carriers. There remains a compelling requirement for antibiotic-locks effective against MRSA.     

Colonization by methicillin-resistant Staphylococcus aureus is a predictive factor for the resistance phenotype of an infectious strain of S. aureus

OBJECTIVE: To assess the predictive value of a previous colonization with methicillin-resistant Staphylococcus aureus for the resistance pattern of a bacteriological specimen significantly positive to S. aureus. STUDY DESIGN: Retrospective study of patients' files. PATIENTS: Patients admitted for at least 48 hours in a surgical intensive care unit from April 1, 1996 to December 31, 1997. METHODS: Collection of patients' characteristics and chronology of positive microbiological specimens with methicillin-susceptible (MSSA) or -resistant (MRSA) S. aureus from medical and laboratory records. During the study period, screening for nasal or perineal colonization with MRSA was systematically performed on admission and weekly thereafter. RESULTS: The files of 540 patients were reviewed. MSSA and MRSA infections occurred in 7% (39/540) and 4% (20/540) of the patients respectively. By opposition with MSSA infections, MRSA infections occurred more frequently in patients previously colonized with MRSA (13 infections in 63 colonized patients [21%] versus 7 infections in 477 non-colonized patients [2%], odds ratio = 18, confidence interval: 6-51, P < 0.0001). The median delay between colonization and infection was 5 days. The positive and negative predictive values for previous colonization with MRSA to predict infection with MRSA in presence of a bacteriological specimen significantly positive with S. aureus were 81 and 84%, respectively. CONCLUSION: The probabilistic use of a glycopeptide in presence of a bacteriological specimen significantly positive with S. aureus should be limited to patients already colonized with MRSA, in order to decrease the abusive administration of these antibiotics.     

Impact of new methicillin-resistant Staphylococcus aureus carriage postoperatively after living donor liver transplantation

BACKGROUND: Preoperative carriage of methicillin-resistant Staphylococcus aureus (MRSA) is associated with an increased risk of MRSA infection after liver transplantation. It is not known, however, whether new MRSA carriage postoperatively also increases the risk of MRSA infection after liver transplantation. METHODS: We retrospectively reviewed the data from 242 adult patients who underwent living donor liver transplantation (LDLT) including microbiological and medical records from admission to 3 months after LDLT. Uni and multivariate analyses were performed to identify independent risk factors for postoperative MRSA infection among preoperative noncarriers of MRSA. RESULTS: Postoperative MRSA infection occurred in 18 of 219 preoperative noncarriers of MRSA by median postoperative day 26. Operation time of at least 16 hours and postoperative colonization with MRSA independently predicted postoperative MRSA infection. CONCLUSION: Postoperative surveillance cultures should be performed periodically after liver transplantation to identify high-risk candidates for postoperative MRSA infection, even among preoperative noncarriers of MRSA.     

Nosocomial MRSA infection in vascular surgery patients: impact on patient outcome

Although methicillin-resistant Staphylococcus aureus (MRSA) infection is a worldwide problem, data on its significance among vascular surgery patients remain scant and conflicting. This study was designed to evaluate the association between nosocomial MRSA infection and patient outcome following vascular surgery procedures. Outcomes among patients with MRSA infection were also compared to those infected with methicillin-sensitive Staphylococcus aureus (MSSA). All patients admitted to a tertiary care Vascular Surgery ward during the year 2002 were included in this retrospective review. In addition to information on demographic and comorbid conditions, data on surgical interventions, nosocomial infection incidence rates as defined by the Center for Disease Control guidelines, and MRSA screening results were collected. Primary outcome was in-hospital death. Secondary outcomes measures included length of hospital stay, readmissions, or repeat surgeries, and ICU admissions. Of a total of 408 subjects, 110 were documented with a nosocomial infection (27.0%). Of these, 16 patients (3.9%) were colonized with MRSA on screening at time of admission, 22 (5.4%) had acquired MRSA infection during hospitalization, and 15 (3.7%) had MSSA infection. Patients with MRSA, MSSA, and non-MRSA infection had similar baseline characteristics except for hypertension and tobacco use. Age and MRSA infection were significant risk factors for in-hospital deaths (OR 1.07, 95% CI 1.01-1.13, p = 0.01 and OR 7.44, 95% CI 1.63-33.9, p = 0.01, respectively). Adjusted for the effects of age, MRSA infection remained a significant independent risk factor associated with in-hospital deaths (OR 4.38, 95% CI 1.09-17.7, p = 0.04). After adjustment for baseline risk factors, MRSA infection was also independently associated with secondary outcome measures. Although risks of non-MRSA infections were also associated with adverse outcomes in the multivariate analyses, MRSA posed higher risks, as reflected by higher odds ratio in all instances. The 22 patients with documented MRSA infection had significantly longer hospital stays than those with MSSA infection (median 24 days vs 8 days, p = 0.02). However, no significant differences were noted between the 2 groups in terms of secondary outcome. These results show that MRSA infection is a significant risk factor for adverse clinical outcomes among patients undergoing vascular surgery procedures. Infection with MRSA results in a greater risk of these outcomes when compared with non-MRSA infection. However, despite concerns regarding the virulence of this strain of staphylococcus, patients infected with MRSA had no higher rates of morbidity or mortality except for increased length of hospital stay when compared to patients with MSSA.     

Methicillin-resistant Staphylococcus aureus infection in liver transplantation: a matched controlled study

The purpose of this study was to evaluate the clinical impact of methicillin-resistant Staphylococcus aureus (MRSA) infections on transplant recipients. METHODS: Liver and kidney recipients with MRSA infections were retrospectively identified and compared to an age, gender, UNOS status, organ transplanted, and transplant date matched (2:1) non-MRSA-infected recipient control group. All MRSA infections were initially treated with vancomycin, and four (33%) liver recipients were converted to linezolid therapy after failing to improve with vancomycin. RESULTS: The overall MRSA infection incidence was 1.4% (24/1770) with MRSA more common in liver (3.75%; 12/320) than kidney transplants (0.8%; 12/1450) (P < .001). The most common sites of MRSA infection were blood (42%), lung (38%), and abdomen (29%). The MRSA group had a greater percentage of prior antibiotic usage (79% vs 40%; P < .0015). The MRSA group experienced more posttransplant complications (52% vs 19%; P < .011)), and exhibited a trend toward greater length of stay in the intensive care unit (7.8 vs 4.6 days; P = .09), but not overall length of stay. Survival was similar in MRSA and non-MRSA groups (75% vs 88%; P = .17). No significant differences in mortality were noted between liver and kidney recipients infected with MRSA (P = .6). CONCLUSION: MRSA infection is associated with a higher incidence of posttransplant complications and antibiotic usage in both liver and kidney recipients compared to patients with MRSA infection.     

Gram-positive bloodstream infections in liver transplant recipients: incidence, risk factors, and impact on survival

The objective of the study was to assess the incidence, risk factors, and survival of gram-positive bloodstream infections (GP-BSI(s)) among liver transplant recipients during the first year after transplantation. Between October 2000 and September 2006, 42 episodes of GP-BSI(s) occurred in 205 patients with an overall incidence of 0.20 episodes/patient. Coagulase-negative staphylococci were detected in 45.2% of cases, Enterococcus species in 42.9% (E faecalis, eight; E faecium, seven; E avium, two; E gallinarum, one) and Staphylococcus aureus in 11.9%. Retransplantation was the only independent risk factor for GP-BSI (odds ratio [OR], 0.253; 95% confidence interval (CI), 0.089 to 0.715; P = .009). Thirty-day mortality rate was 28.5% and S aureus infections were related to a poorer outcome. It is noteworthy that all the isolates of S aureus were methicillin-resistant. Ampicillin was inactive against all the strains of E faecium and 50% of E avium isolates, but active against all E faecalis and E gallinarum strains. All the isolates were glycopeptide-susceptible. No significant differences in mortality rate were observed in relation to sex, etiologies of end-stage liver disease, cytomegalovirus infection/reinfection, type of donor, rejection, or retransplantation. GP-BSI, the only independent risk factor for death (OR, 0.262; 95% CI, 0.106 to 0.643; P = .003), reduced the survival rate by 26% in the first year posttransplant. In conclusion, GP-BSI(s) impact significantly on morbidity and mortality posttransplant, particularly among retransplantations. Control measures are required to reduce the incidence of GP-BSI(s) in liver transplant recipients. These findings must be considered when empirical antimicrobial therapy is indicated while awaiting blood-culture results.     

成人肝移植术后急性肾损伤的发生与术后凝血功能变化的关系

目的 探讨肝移植术后凝血功能改变对急性肾损伤(AKI)发生的影响.方法 回顾性分析符合纳入和排除标准的245例肝移植受者的临床资料,根据肝移植术后是否发生AKI,将受者分为AKI组(99例)和非AKI组(146例),总结肝移植术后AKI的发生情况,并收集受者的围手术期指标,对肝移植受者术后发生AKI的危险因素进行单因素...     

Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus

INTRODUCTION: An increase in the incidence and severity of acute osteoarticular infections in children was perceived after the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) in our community. This study was performed to describe changes in the epidemiology and clinical features of acute osteoarticular infections. METHODS: The records of patients discharged from Le Bonheur Children's Medical Center with a diagnosis of acute osteoarticular infection between 2000 and 2004 were reviewed. Data regarding signs and symptoms, diagnostic testing, therapeutics, surgery, and hospital course were collected. RESULTS: There were 158 cases of acute osteoarticular infection. The incidence increased from 2.6 to 6.0 per 1000 admissions between 2000 and 2004. The proportion of infections caused by methicillin-susceptible S. aureus (MSSA) remained constant (10%-13%) and that caused by MRSA rose from 4% to 40%. There was no difference between MRSA and MSSA patients in the duration of fever or pain before diagnosis. Seventy-one percent of patients with MRSA had subperiosteal abscesses compared with 38% with MSSA (P = 0.02). Ninety-one percent of MRSA patients required a surgical procedure compared with 62% of MSSA patients (P < 0.001). Median hospital stay was 7 days for MSSA patients and 10 days for MRSA patients (P = 0.0001). Three patients developed chronic osteomyelitis, 2 with MRSA. There was no association between a delay in institution of appropriate antibiotic therapy and presence of subperiosteal abscess (P = 0.8). CONCLUSIONS: There has been an increase in the incidence and severity of acute osteoarticular infections in Memphis. Patients with community-associated MRSA infections are at higher risk of subperiosteal abscess requiring surgical intervention.     

Who among cytomegalovirus-seropositive liver transplant recipients is at risk for cytomegalovirus infection?

A vast majority of the transplant recipients are cytomegalovirus (CMV)-seropositive (R+). We sought to assess variables predictive of CMV infection, specifically in R+ liver transplant recipients. Study patients comprised 182 consecutive liver transplant recipients who survived at least 14 days after transplantation. Surveillance testing was used to detect CMV infection. Pre-emptive therapy was employed for the prevention of CMV disease, however, no antiviral prophylaxis was used for CMV infection. CMV infection developed in 32.5% (38 of 117) of R+ patients, 84.6% (33 of 39) of R-/D+, and 3.8% (1 of 26) of R-/D- patients. In R+ patients, Hispanic race (21.6% vs. 7.8%, P = 0.06), donor CMV seropositivity (73.7% vs. 45.6%, P = 0.005), and hepatocellular carcinoma (23.7% vs. 6.3%, P = 0.05) correlated with a higher risk of CMV infection. In a multivariate model, Hispanic race (OR: 3.5, 95% CI: 1.03-11.6, P = 0.045), donor CMV serostatus (OR: 4.0, 95% CI: 1.6-10.2, P = 0.003) and hepatocellular carcinoma (OR: 5.8, 95% CI: 1.6-20.5, P = 0.006) were all significant independent predictors of CMV infection. The aforementioned variables did not portend a higher risk of CMV infection in R-/D+ patients; donor CMV seropositivity overwhelmed all other risk factors in R- patients (P < 0.00001). In conclusion, CMV-seropositive liver transplant recipients at risk for CMV infection can be identified based on readily assessable variables. Preventive strategies may be selectively targeted toward these patients.     

股疝患者急诊手术的危险因素分析

目的探讨股疝患者急诊手术的相关危险因素。 方法回顾性分析2013年1月至2018年1月,中信惠州医院行股疝手术病程超过1个月103例患者的临床资料。根据手术时机分为急诊手术组（53例）和择期手术组（50例）。对2组患者的临床指标进行单因素分析,将单因素分析中具有统计学意义的因素纳入多因素Logistics回归分析,以确定其是否为股疝急诊手术的独立危险因素。 结果单因素分析结果显示,2组间年龄、病程、肝硬化、高血压和慢性阻塞性肺疾病比较,差异均有统计学意义（P<0.001、0.004、0.002、0.036、0.001）。Logistic多因素回归分析显示,年龄、病程、肝硬化和慢性阻塞性肺疾病是急诊手术的独立危险因素（OR=1.062、1.099、11.408、5.558,P=0.026、0.016、0.034、0.042）。 结论高龄、病程较长、合并肝硬化和合并慢性阻塞性肺疾病对病程超过1个月的股疝患者的手术时机选择的影响不容忽视。     

Randomized controlled trial of prophylactic rifampin for peritoneal dialysis-related infections

Staphylococcal infections are a major cause of catheter infections and peritonitis in peritoneal dialysis patients. Since catheter-related infections are associated with nasal carriage of Staphylococcus aureus in this population, we studied the effect of intermittent rifampin, an antibiotic known to decrease S aureus nasal carriage, on catheter-related infections and peritonitis. We randomly assigned 64 patients to receive either rifampin 300 mg twice daily for 5 days every 3 months or no treatment. The rifampin-treated patients had a significant delay in time to first catheter-related infection (P less than 0.015) and significantly fewer catheter-related infections overall (P less than 0.001). The catheter-related infection rate in rifampin-treated patients was .26 per patient-year versus .93 per patient-year in untreated patients. Multivariate analysis defined baseline colonization of nares or catheter exit-site and prior renal transplant as risk factors for catheter-related infections. There was no significant difference in peritonitis rates between groups, although the trend was for a delayed time to first episodes and fewer episodes in rifampin-treated patients. Adverse effects necessitated withdrawal of rifampin in four patients. We conclude that intermittent rifampin administration is effective in decreasing catheter-related infections in a peritoneal dialysis population.     

Carriage of methicillin-resistant Staphylococcus aureus is associated with an increased risk of infection after liver transplantation

Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of sepsis in patients with cirrhosis and after liver transplantation. The association between nasal carriage of MRSA and sepsis in these patients is unclear. The goal of this study was to investigate the relationship between MRSA carriage before liver transplantation and subsequent sepsis after transplantation. This was a retrospective study of 374 consecutive adults who underwent orthotopic liver transplantation between 1998 and 2001 and for whom full data were available. Of these, 157 had been screened for MRSA as part of a study assessing the prevalence of MRSA infection. All MRSA carriers were treated with nasal mupirocin and chlorhexidine baths. The records of MRSA carriers and noncarriers were analyzed for Child and Model for End-Stage Liver Disease (MELD) score, posttransplantation MRSA, and other infections and mortality. Of the 157 patients who had an MRSA screen, 35 patients were MRSA nasal carriers. These carriers had significantly greater MELD score (mean, 16.2 compared with 13.1; P = .02) and Child scores (mean, 10 versus 9; P = .001) than noncarriers. The incidence of posttransplantation MRSA infection was significantly higher in MRSA carriers (31% versus 9%; P = .002). The incidence of other posttransplantation infection was not significantly different in the two groups. There was no significant difference in survival between the two groups (1-year patient survival, 74% and 82%, respectively). Patients carrying MRSA are predisposed to an increased risk of sepsis after liver transplantation with a trend to increased mortality. Screening for MRSA should be considered in high-risk patients being assessed for liver transplantation. (Liver Transpl 2003;9:754-759.)