Bacteremia associated with percutaneous transluminal coronary angioplasty

Bacteremia after diagnostic cardiac catheterization is uncommon, but bacteremia after percutaneous transluminal coronary angioplasty (PTCA) has not been studied prospectively. Unlike diagnostic cardiac catheterization, PTCA involves the use of an indwelling arterial sheath after completion of the procedure, which is connected to a pressurized heparin solution, both of which increase the risk of local infection and/or bacteremia. During a 16-week period, we prospectively evaluated patients undergoing 164 PTCA procedures in order to determine the frequency of bacteremia and the significance of fever in this patient population. Blood cultures were obtained from the femoral catheter at the conclusion of the procedure and again 30 min later from the indwelling arterial sheath. Temperature was recorded every 30 min for 2 h following PTCA, then every 4 h over the subsequent 36-hr period. Bacterial isolates were recovered from 23/286 blood cultures (8.0%), with Staphylococcus epidermidis the most common organism present (74%). Only one isolate of Staphylococcus aureus was considered to represent true bacteremia and corresponded with the only documented infectious complication. Fever, defined as ?101°F developed in four (2.4%) patients but was procedure related in only one case. The use of the ipsilateral femoral artery for repeat procedures was not associated with either positive blood cultures or difference in maximum temperature elevation. We conclude the overall risk of bacteremia after PTCA is low; therefore, antimicrobial prophylaxis is not warranted. © 1995 Wiley-Liss, Inc.     

On denial

Evaluation of 612 episodes of gram-negative bacteremia over a 10-year period demonstrated its progressively increasing frequency. This increase was associated with an increasing proportion of patients with more severe underlying disease, increasing patient age, increasing frequency of cardiac surgery and manipulative procedures, and increasing frequency of treatment with antibiotics, corticosteroids and antimetabolites in patients with bacteremia. Fatality rates paralleled the severity of the host's underlying disease as noted in previous reports. The urinary tract was the most frequent source of bacteremia, but in 30 per cent of the patients, predominantly those with more severe underlying disease, the original source could not be identified. Of all blood cultures obtained in these patients, 72 per cent were positive. Bacteremia was of low magnitude with 77 per cent of the patients having quantitative blood cultures with less than 10 gram-negative bacilli per milliliter of blood. Escherichia coli was the most frequent etiologic agent followed in frequency by Klebsiella-Enterobacter-Serratia species, Pseudomonas aeruginosa, Proteus and Providencia species, and species of Bacteroides. Sixteen per cent of the bacteremias were polymicrobic. K and O-antigen typing of Escherichia coli and capsular typing of K. pneumonias demonstrated that a large number of serologic types of these strains were responsible for bacteremia. Over-all, bacteremia caused by multiple species of bacteria was associated with higher fatality rates, but no significant differences in fatality rates could be demonstrated for bacteremias caused by individual species of gram-negative bacilli when comparisons were made between patients with underlying diseases of similar severity. The presence or type of K-antigen did not influence the lethality of Esch. coli infections. Although some O-antigen types, 0:4, 0:6 and 0:8, were associated with higher fatality rates than other O-antigen types, “rough” or autoagglutinable Esch. coli were as lethal as smooth strains. These findings indicate that bacterial factors, other than antibiotic resistance, have little influence on the outcome of gram-negative bacteremia and that gram-negative bacilli function primarily as “opportunistic” pathogens.     

Bacterial endocarditis in a patient with mitral valve prolapse.

Bacterial endocarditis developed following dental manipulation in a child with mitral valve prolapse. Antibiotic prophylaxis is recommended for patients with this cardiac abnormality who undergo procedures that may be associated with bacteremia.     

Pacemaker associated infection due to a corynebacterium species

Pacemaker associated infection (PAI) is a rare but often serious complication of permanent or temporary transvenous cardiac pacemakers. The major risk factor is recent or multiple pacemaker manipulations or surgical procedures. A PAI can occur at the time of insertion, from contiguous spread to the access site, or from transient bacteremia. We report a case of PAI of a retained pacemaker electrode from which a Corynebacterium species was isolated. Multiple preoperative cultures were sterile, but bacteria were isolated from tissue removed at surgery, and were seen around the wire deep inside a thrombus. The importance of cultures and special stains (including electron microscopy) of surgical materials is stressed, especially when dealing with microorganisms of ordinarily low virulence, or those that are commonly considered laboratory contaminants.     

Prevention of bacterial endocarditis

Prevention of bacterial endocarditis is aimed at limiting the frequency, size, and duration of transient bacteremia with subsequent bacterial implantation on valvular endothelium in patients with cardiopathy. Any procedure involving mucosa rich in normal flora or an infectious site can result in bacteremia, which can be minimized by selecting diagnostic and therapeutic procedures which are least traumatic. In addition, proper antibiotic prophylaxis should be administered according to the most frequently encountered bacteria: Streptococcus viridans during dental manipulations, enterococci during urogenital or intestinal procedures, and staphylococcal species from skin lacerations or cardiac surgery. The different antibiotic prophylactic regimens suggested at the present time vary according to the patient and the particular circumstances surrounding his illness. These regimens should be modified according to future epidemiologic findings in bacterial endocarditis.     

Stenotrophomonas maltophilia meningitis,bacteremia and respiratory infection

Stenotrophomonas maltophilia is an increasingly recognized cause of nosocomial infection of special interest because of its resistance to multiple antimicrobial agents. We report a case of generalized infection by S. maltophilia, including meningitis, bacteremia and respiratory tract infection, in a patient who had undergone multiple neurosurgical procedures and who was treated with trimethoprim-sulphamethoxazole.     

Risk factors for Acinetobacter baumannii nosocomial bacteremia in critically ill patients: a cohort study.

Nosocomial bacteremia caused by Acinetobacter baumannii (AB) is of increasing concern in critically ill patients, and the risk factors for this infection are not well established. An inception cohort study in a 40-bed medical and surgical intensive care unit (ICU) at a single institution was conducted during a 2-year period to determine the risk factors for AB nosocomial bacteremia. Risk factors related to the underlying diseases, the clinical picture at admission, and those acquired during the stay in the ICU were recorded upon admission and daily throughout the ICU stay. We defined an "invasive procedures index" as the number of invasive procedures performed every day during the ICU stay before the onset of AB bacteremia divided by the number of days in the ICU before the onset of AB bacteremia. Risk factors that were independently associated with AB bacteremia were immunosuppression, unscheduled admission to the hospital, respiratory failure at ICU admission, previous antimicrobial therapy, previous sepsis in the ICU, and the invasive procedures index.     

Infectious complications of endoscopic procedures in bone marrow transplant recipients

The prevalence of clinically relevant bacteremia after endoscopic procedures in bone marrow transplant recipients was assessed retrospectively. Bacteremia, within 24 hr of procedure, was defined as positive blood cultures, while hypotension and temperature greater than 38° C were taken as possible indicators of bacteremia. Sixty-seven procedures were performed in 53 endoscopic sessions (upper endoscopy 37, flexible sigmoidoscopy 7, upper endoscopy + flexible sigmoidoscopy 8, colonoscopy 1). Twenty-five endoscopic sessions were performed in patients receiving broad-spectrum antibiotics and 28 sessions in patients not receiving antibiotics. Both groups were comparable with respect to patient characteristics, procedures performed, and immune status. No patient in either group developed hypotension. One patient developed fever after flexible sigmoidoscopy; no source of fever was identified. We conclude that: (1) there were no episodes of clinically relevant bacteremia attributable to endoscopic procedures, and (2) not all bone marrow transplant recipients require routine antibiotic prophylaxis prior to endoscopic procedures.     

Superior vena cava and right atrium wall infective endocarditis in patients receiving hemodialysis

Infective endocarditis is significantly more common and causes greater morbidity and mortality in patients receiving hemodialysis than in the general population. Episodes of bacteremia during hemodialysis are primarily the result of frequent vascular access through an arteriovenous fistula, a vascular graft, or an indwelling vascular catheter. This leads to dialysis access infection and secondary bacteremia. We describe 4 cases of patients receiving hemodialysis, with an indwelling intravascular dialysis catheter, who developed right-sided endocarditis with vegetations located exclusively on the superior vena cava and right atrium wall. All patients had persistent bacteremia with Staphylococcus, secondary to an indwelling intravascular hemodialysis catheter, which led to seeding of the right-sided cardiac wall, causing infective endocarditis. The rates of acceptance for hemodialysis are increasing, along with improved survival in this group of patients. This will probably lead to an increase in the incidence of infective endocarditis, with atypical presentations such as superior vena cava and right-sided cardiac wall endocarditis.     

Incidence of endotoxemia in pigs with ischemic hepatic necrosis treated by hemodialysis. Prevention of endotoxemia with lactulose

The incidences of endotoxemia and bacteremia were evaluated in 30 pigs with ischemic hepatic necrosis treated by hemodialytic procedures. Prior to induction of hepatic ischemia, ten pigs underwent bowel cleansing by means of an oral dose of magnesium sulfate, and 20 received a combination of magnesium sulfate and lactulose. Endotoxemia and bacteremia seldom occurred during the development of hepatic encephalopathy, but the incidence of both increased markedly shortly before death. Pigs pretreated with magnesium sulfate and lactulose however did not develop preterminal endotoxemia. A significant relation between endotoxemia or bacteremia and survival was not found, irrespective of pretreatment with lactulose. Of the positive limulus tests, 67% were accompanied by a positive blood culture, while 42% of all positive blood cultures were associated with a positive limulus test. Dialysis with dialysates contaminated with endotoxins did not increase the risk of endotoxemia. It is concluded that in an animal model of ischemic hepatic necrosis (1) endotoxemia and bacteremia appear mainly in the preterminal stage, but do not influence the duration of survival significantly; (2) lactulose prevents endotoxemia and (3) dialytic procedures do not increase the risk of endotoxemia and bacteremia.     

Penicillin prophylaxis in children with cardiac disease: postextraction bacteremia and penicillin-resistant strains of viridans streptococci

The incidence of postextraction bacteremia in 82 children with dental foci and cardiac disease given parenteral penicillin prophylaxis was assessed 5 min after extraction. Penicillin concentrations were determined in blood samples obtained at the same time. Before extraction, cultures were taken from the gingival sulcus. Postextraction bacteremia occurred in 21% of the patients and was due to penicillin-sensitive microorganisms in 10 and to both penicillin-sensitive and penicillin-resistant microorganisms in seven children. In three of these children penicillin-resistant viridans streptococcal strains were isolated. Penicillin-resistant viridans streptococci were present in the gingival sulcus flora of 39% of the children, but a relationship between the presence of such strains in the gingival sulcus and the occurrence of postextraction bacteremia could not be demonstrated. There was no difference in the serum penicillin concentrations found in children with bacteremia due to penicillin-sensitive or penicillin-resistant microorganisms, or between the concentrations in children with and without bacteremia.     

A comparison of hospital and community-acquired infective endocarditis.

The epidemiology, clinical features, microbiology and outcome of 30 episodes of nosocomial endocarditis occurring over a 13-year period were reviewed and compared with 148 cases of community-acquired endocarditis. Twenty-eight patients (93%) had been in hospital for > 1 week and 10 patients (33%) for > 1 month when they developed endocarditis. Left-sided infection was most frequent; only 3 cases involved the tricuspid valve. Compared with community-acquired infection, patients tended to be older, had a greater incidence of congestive cardiac failure (p = 0.001) or hypotension (p = 0.0008) at presentation and were more likely to have bacteremia after an invasive procedure (83 vs 31%; p < 0.00001). Intravascular devices were the presumed source of bacteremia in 11 cases (37%); the same organism was isolated from both the blood and the suspected source of infection. Staphylococcus aureus was the most frequent causative organism, accounting for 17 episodes (57%), including 4 (13%) due to methicillin-resistant strains. Nosocomial endocarditis had a significantly higher mortality than did community-acquired infection (40 vs 18%; p = 0.02). Eight patients (27%) needed valve replacement. Proper adherence to protocols for management of intravascular devices and appropriate antimicrobial prophylaxis before procedures may have prevented endocarditis in 15 of 30 patients.     

非计划二次开胸术后并发症危险因素分析

目的：分析心脏直视术后非计划二次开胸术后并发症的危险因素,为临床心脏直视术提供高度预警理论依据。方法 总结回顾2011年3月至2014年11月期间,共施行心脏外科手术1600例,其中85例患者行非计划二次开胸手术,其中40例出现纵膈感染,肾功能衰竭,多脏器功能衰竭等并发症;余65例无并发症,分别给患者性别、年龄、体重、首次手术方式、术前诊断、二次开胸时机、术前合并症,恶病质,菌血症,分别赋值,运用logistic回归分析法,筛选出危险因素。结果：性别、年龄、体重、首次手术方式、二次开胸时机、菌血症为非计划二次开胸术后并发症的危险因素。结论 充分评估危险因素,为临床首次直视心脏手术提供预警,竭力力避免非计划再次手术。保证临床治疗效果;     

Bacteremia following diagnostic and therapeutic ERCP.

The occurrence of bacteremia in association with diagnostic or therapeutic ERCP was studied in 180 patients undergoing a total of 194 examinations. Nineteen (15%) of 126 diagnostic procedures and 18 (27%) of 68 therapeutic procedures were associated with bacteremia (p less than 0.1). Nine patients had polymicrobial bacteremia and a total of 16 species were detected. Different streptococci, mainly alpha-hemolytic, were the most common bacteria which were identified in 38% of the bacteremic patients. There were no significant differences with regard to the occurrence of fever, pancreatitis, or septic complications between the diagnostic and therapeutic groups of patients. Neither did the complication rate in patients with bacteremia differ from that in patients without bacteremia, whether the procedure was diagnostic or therapeutic. Complication rates did not differ between patients with and patients without pancreaticobiliary obstruction. However, the majority of patients with biliary stasis had drainage with relief of the obstruction at the time of the diagnostic ERCP. We conclude that general routine antibiotic prophylaxis is not indicated in patients undergoing diagnostic or therapeutic ERCP. The question whether such prophylaxis should be given with certain diagnoses or treatments, or in patients with valvular heart disease, remains to be answered in controlled randomized studies.     

Risk Factors of Post Endoscopic Retrograde Cholangiopancreatography Bacteremia

Background/Aims

Bacteremia following endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication, but the risk factors for this condition have not yet been clearly determined. Thus, the aim of this study was to investigate the risk factors of post-ERCP bacteremia.

Methods

Among patients who underwent ERCP from June 2006 to May 2009, we selected patients without any signs of infection prior to the ERCP procedures. Of these patients, we further selected those who experienced bacteremia after ERCP as well as two-fold age and sex-matched controls who did not experience bacteremia after ERCP procedures. We compared clinical, laboratory and technical aspects between these two groups.

Results

There were 70 patients (3.1%) who developed bacteremia after ERCP. In the multivariate analysis, a history of previous liver transplantation, an elevated serum alkaline phosphatase level and an endoscopic retrograde biliary drainage procedure were independent risk factors of post-ERCP bacteremia (p=0.006, p=0.001, and p=0.004, respectively). The microbiologic analysis revealed the presence of gram-negative organisms in 80% of the cases, and 11 patients had infections with bacteria expressing extended spectrum β-lactamases. Pseudomonas infection was significantly more common in patients who received liver transplantation as compared to patients without transplantation (p=0.014).

Conclusions

A history of liver transplantation, elevated serum alkaline phosphatase levels and endoscopic retrograde biliary drainage procedure were independent risk factors of post-ERCP bacteremia and require additional attention in future studies.     

Bacteremias due to Citrobacter diversus and Citrobacter freundii. Incidence, risk factors, and clinical outcome

From 1974 to 1982, 38 patients developed Citrobacter bacteremia at two adult community-teaching hospitals in the Detroit Medical Center (incidence, 1.2 cases per 10,000 discharges). Citrobacter accounted for 0.7% of all bacteremias during the study period. Of 31 cases reviewed, Citrobacter bacteremia frequently developed in elderly patients (65%) and was hospital acquired (77%). Initial sites of infection included the urinary tract (39%), gastrointestinal tract (27%), wound (10%), and unknown (13%). More bacteremias caused by Citrobacter diversus tended to arise from the urinary tract, while patients with Citrobacter freundii bacteremia had significantly more gallbladder disease. Patients with Citrobacter bacteremia were more likely than patients with Escherichia coli bacteremia to have had additional pathogens in the bloodstream, to develop bacteremia in the hospital, and to have undergone invasive procedures contributing to infection. Significant differences were not observed in demographic, host, or other epidemiologic or clinical factors examined. Of patients with Citrobacter bacteremia, 48% died.     

Bacteremia with esophageal dilation

(GUMMI BEARS)Background: Antibiotic prophylaxis has been recommended for selected patients undergoing esophageal stricture dilation because of a reported high rate of bacteremia. The aim of this study was to determine the rate of bacteremia after esophageal dilatation in a large series and the source of the organisms recovered. Methods: Blood cultures and oral temperatures were obtained before esophageal dilation and at 5 and 30 minutes after dilation. Dilators were cultured immediately before dilation. Procedural data collected included type of dilation, number of passes, and presence of malignancy. Results: Of 100 procedures in 86 patients undergoing esophageal dilation, 22 (22%) were associated with a positive post-dilation blood culture. Bacteremia was more frequent with dilation of malignant strictures compared with benign strictures (9 of 17 [52.9%] vs. 13 of 83 [15.7%], respectively, p = 0.002) and with passage of multiple dilators compared with passage of a single dilator (16 of 46 [34.8%] versus 6 of 54 [11.1%], respectively, p = 0.007). Bacterial isolates from 22 positive blood cultures matched those from a dilator in only one episode (4.5%). Conclusion: The rate of bacteremia after esophageal dilation is 22% and is associated with dilation of malignant strictures or passage of multiple dilators. Organisms cultured from the blood are not transmitted from the dilator. (Gastrointest Endosc 1998;48:563-7.)     

Urinary tract infection.

Urinary tract infections are the most common bacterial infections experienced by elderly patients. These infections are often asymptomatic, although on occasion they produce discomfort for selective older patients (particularly those with obstructive uropathy), and present a risk for bacteremia, septic shock, adult respiratory distress syndrome, and death. The limited available data suggest that there are major differences with regard to pathogenesis, microbiology, clinical features, laboratory abnormalities, and therapy between young and elderly women who develop symptomatic pyelonephritis. There is a need to provide a standard antibiotic prophylaxis program to those elderly patients with specific cardiac conditions who are scheduled to undergo urinary procedures.     

The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome

Cardiovascular infections due to Salmonella enterica are infrequently reported, so their clinical features, prognosis, and optimal treatment are not completely known. Mortality associated with aortitis and endocarditis caused by nontyphoidal Salmonella remains exceedingly high.In this review of cases of cardiovascular infections due to Salmonella enterica studied in 2 hospitals in Madrid, we tried to assess the clinical manifestations and the procedures leading to diagnosis in addition to treatment and outcome. To complete the spectrum of infections related to cardiovascular surgery, cases of postoperative mediastinitis, pericarditis, and infections associated with cardiac devices were also included.Twenty-three patients were reviewed: 11 had mycotic aneurysms; 7 had endocarditis; 2 had device-related infections; and 3 had pericarditis, mediastinitis, and infection of an arteriovenous fistula, respectively. The risk of endovascular infection in patients older than 60 years with bacteremia due to nontyphoidal Salmonella was 23%. Most patients with aortitis had risk factors for atherosclerosis, and 6 had preexisting atherosclerotic aortic aneurysms. All except 1 patient with endocarditis had underlying cardiac disorders. Acquired immunodeficiency disease (AIDS) was a major risk factor for salmonella bacteremia in 1 patient with aortitis and 1 with endocarditis. Fever, unremitting sepsis, "breakthrough" and relapsing bacteremia were the most common clinical findings. In addition, abdominal or thoracic pain and cardiac failure and pericarditis were common features in patients with aortitis and endocarditis respectively. Computed tomography (CT) scan, arteriography, and echocardiography were the main diagnostic tools.Mortality associated with mycotic aneurysms and endocarditis due to S. enterica was 45% and 28%, respectively. Thoracic aneurysms, rupture, and shock at the time of diagnosis were associated with increased mortality in patients with aortitis. In situ bypass grafting was successfully performed in most cases. After surgery, antimicrobial therapy was continued for 4-9 weeks. No relapses were observed after a mean follow-up of 64 months. Antimicrobial therapy alone or combined with valve replacement or excision of a ventricular aneurysm was successful treatment for most patients with salmonella endocarditis. Combined medical and surgical treatment was required for patients with mediastinitis and pericarditis, and patients with device-related infections needed removal of the complete device.Diagnosis of aortitis due to nontyphoidal Salmonella should be established as early as possible to reduce mortality. Patients older than 60 years who have positive blood cultures for Salmonella along with fever and back, abdominal, or chest pain should have an extensive workup for infective aortitis. Immediate bactericidal antimicrobial therapy should be started and a CT scan should be performed on an emergency basis. If a mycotic aneurysm is found, surgical resection should follow as soon as possible. Resection of the aneurysm with in situ bypass grafting is the procedure of choice. Postoperative antimicrobial therapy for 6-8 weeks seems enough to avoid relapses. Optimal treatment of patients with endocarditis occurring on ventricular aneurysms must include resection of the aneurysmal sac. Salmonella endocarditis can be successfully treated with antimicrobials alone. Valve replacement should be reserved for patients with cardiac failure or persisting sepsis, and for those who relapse after discontinuation of antimicrobial therapy.     

Sustained bacteremia associated with transjugular intrahepatic portosystemic shunt (TIPS).

Transjugular intrahepatic portosystemic shunt (TIPS) has become a routine procedure in patients with portal hypertension, yet there are few data concerning the incidence of bacteremia associated with this shunt. All patients who underwent TIPS placement at a university hospital from January 1992 through January 1999 were studied. Ninety-nine TIPS were placed, and 10 patients subsequently developed sustained bacteremia; 5 patients had no identifiable source of bacteremia despite rigorous evaluation and were presumed to represent TIPS infections, for an estimated annual incidence of 7 cases/1000 TIPS procedures. Case patients developed bacteremia a median of 100 days after TIPS placement (range, 6-732 days). Bacteremia resolved in all patients after treatment with appropriate intravenous antibiotics (median, 2 weeks of therapy). Although the incidence of TIPS-associated bacteremia appears low, the increasing frequency of this procedure suggests that more information is needed to define this entity and to develop appropriate treatment recommendations.