Volume 8, Issue 3, 2000
Review
The role of mycoses in intrabdominal infections
Marvaso Alberto
In the last few years, there has been a continuous, marked increase in serious mycotic infections, with a high incidence of morbidity and mortality especially among patients undergoing surgery in Intensive Therapy Units. Many risk factors are associated with the development of mycotic infections, amongst which the following may be highlighted: immunosuppression, protracted antibiotic treatment, long NPT, serious trauma, central venous catheterization and, in critical patients, a high APACHE II score.
Mycotic peritonitis, an increasingly rare complication found in patients undergoing peritoneal dialysis, seems to be linked to gastric or duodenal perforations treated late (> 24 h) or to secondary, chiefly post-operative peritonitis, in the case of anastomotic dehiscences or fistules, and more generally in surgical patients in unstable conditions, i.e. those with severe acute pancreatitis and cirrhotic imbalances.
In the absence of clear clinical signs of mycotic infection, diagnosis is based on the positivity of the culture test carried out in all explorable sites (expectorate, urine, blood, drainage, ascites, intrabdominal sampling), while positivity of haemoculture alone is a real dilemma for the clinician as it may be the result of transitory fungemia or a widespread infection. As yet, there is no reliable diagnostic test, though histopathology, the general signs of sepsis and positive culture in normally sterile sites are used to provide clear indications.
Until recently, most patients with intrabdominal infections were not treated with general antimycotics, both because of the relatively low probability of developing a systemic infection and the feared toxicity of amphotericine B. Nowadays, this wait-and-see approach has been discarded, such that high-risk patients are recommended early empirical antimycotic treatment or even prophylaxis. The choice of antimycotic agent, dosage and duration of therapy depends on the aetiologic agent isolated, on the source of infection, renal functionality and associated pathologies. In conclusion, while the incidence of serious mycotic infection has sharply increased, an appropriate therapeutic strategy has not yet been definitively identified, due both to the lack of numerically significant clinical studies and especially the extreme variability and complexity of patients to be treated.
Original article
Effects of the introduction of highly active antiretroviral therapy (HAART) on the temporal trend of diagnosis of AIDS and AIDS-defining disorders
Manfredi Roberto,
Chiodo Francesco
Objectives: to assess the features of AIDS and AIDS-defining events during the highly active antiretroviral therapy (HAART) era, compared with those observed before the introduction of HAART.
Methods: the epidemiological, clinical and laboratory characteristics of 72 consecutive patients with AIDS diagnosed from 1997 to 1999, were compared to those of 144 subjects randomly selected from 436 AIDS patients diagnosed from 1985 and 1995, in a case control study.
Results: a sharp drop in AIDS notifications was observed after the introduction of HAART, in association with an increase in mean patient age, and heterosexual transmission of HIV infection. A tendency to reduced frequency of Cytomegalovirus disease, cryptococcosis, mycobacteriosis, cryptosporidiosis and HIV encephalopathy was also noticed, with a slight proportion increase in pneumocystosis, esophageal candidiasis, wasting syndrome, tuberculosis and lymphoma. Non-infectious complications showed a slighly increased frequency during the HAART era, while a mild parallel decrease in overall opportunistic infections was observed. A considerable trend to an increased mean CD4+ lymphocyte count at diagnosis was found during the HAART era for most AIDS-related illnesses (significant for Candida esophagitis, wasting syndrome and tuberculosis) (p<.04). Only seven of the 72 patients with AIDS recognized since 1997 received HAART prior to diagnosis, while the remaining 65 cases HIV infection was detected concurrently with an AIDS-defining event (40 cases), or HAART was refused or carried out with poor adherence (25 patients)
Conclusions: although remarkable changes of AIDS features of AIDS occurred after the widespread use of HAART, early diagnosis and treatment of HIV infection, and careful monitoring of the spectrum of AIDS-related diseases are strongly warranted in order to update and plan future management strategies.
A proposal for guidelines of antimicrobial prophylaxis in surgery and surveillance of their application
Camporese Alessandro,
Calianno Giuseppina
Pharmacoeconomic evaluation of antibiotic therapy in a ward for infections diseases
Sabbatani Sergio,
Cannella Bartolo,
Fulgaro Ciro,
Pipitone Emanuela,
Cesari Raffaella,
Martelli Luisa
For all hospitalized patients admitted in the first six months of 1999, we recorded the data relative to antibiotic therapy (TA) administered, establishing the period of treatment in days and the dosage, including any variations during the period in question. We calculated the prescribed daily dose (PDD) and were thus able to establish the expense incurred in antibiotic therapy, comparing the real overall cost per product used. For all patients, the discharge diagnosis was reported, and the whole case-study was aggregated into homogeneous groups. PDD was compared with DDD (defined daily doses). The Pareto curve was used to highlight the antibiotics with higher overall cost. Besides cotrimoxazole, ceftriaxone and ciprofloxacin were the antibiotics most frequently prescribed, while ceftriaxone, imipenem-cilastatine and vancomycin were the antibiotics incurring the greatest expense. With reference to the average duration of the treatment cycle, ceftriaxone (9.75 dd) and ciprofloxacin tbl (6.75 dd) were the only antibiotics (in monotherapy) used for less than 10 treatment days.
Special attention was paid to analysing the TA costs in treating pneumonia, which accounted for the highest percentage of cases (50 cases). Ceftriaxone, especially pulmonary infections, was the most commonly used drug. In hospitalized subjects treated who show good therapeutic response, we recommend early discharge and continuation of the therapy at home (switch therapy). This strategy will allow the patient to return to his/her family in good time, also thereby reducing hospital management costs.
Current epidemiological and clinical features meningitis in a northern Italian area
De Carlo Antonio,
Roda Rinaldo,
Rossi Maria Rita,
Ceruti Stefano,
Ghinelli Florio,
Libanore Marco,
no surname no name
Objectives: To study etiological, epidemiological and clinical features of 97 cases of acute meningitis.
Methods: Ninety-seven cases of acute meningitis were examined in adult HIV-negative patients admitted to the Infectious Diseases Unit of the Azienda Ospedale-Universita S. Anna in Ferrara. Demographic, etiological, epidemiological and clinical data were analyzed.
Results: All cases were divided into two groups according to the macroscopic aspect of cerebrospinal fluid (CSF): purulent CSF (50 cases) or non-purulent CSF (47 cases). Purulent CSF meningitis more frequently affected male patients (64% vs 47%) and older patients (average 52 vs 44 years). The main epidemiological features in both groups were underlying bacterial diseases (i.e. otomastoiditis and/or sinusitis in 50% of pneumococcal meningitis) and iatrogenic immunodeficiency. From a clinical point of view the following alterations in the state of consciousness (stupor, confusion and coma) were most frequently found in purulent meningitis.
The following non purulent forms of meningitis were diagnosed: 5 tubercular, 3 viral infections, 2 by Listeria monocytogenes, 1 by Entoameba histolytica, 1 by Cryptococcus neoformans and 35 (74,4%) unknown causes. Purulent meningitis were: 20 (40%) Streptococcus pneumoniae, 10 Neisseria meningitidis, 3 Staphylococcus aureus, 2 Escherichia coli, 1 Haemophilus influenzae and 1 Pseudomonas aeruginosa; 13 cases were unidentified.
From 1989 to 1993 and from 1994-98 both groups of meningitis increased; respectively from 17 to 30 cases for non-purulent meningitis and from 18 to 32 cases for purulent meningitis. Meningitis due to Streptococcus pneumoniae increased from 27.7% to 46.8% during the period 1994-98.
Conclusions: The study shows the high incidence of pneumococcal meningitis, during 1994-98, because a large number of patients with sinusitis and otomastoiditis were observed. The incidence of meningococcal meningitis appears stable.
These data confirm the importance of timely diagnosis and correct therapy for such infections with reserved prognosis.
Case report
Abdominal actinomycosis
Giobbia Mario,
Vaglia Alberto,
Fuser Rodolfo,
Caronia Vincenzo,
Battistoli Mauro,
Gualandi Orlando
The authors present a case of abdominal actinomycosis in a 65-year old woman undergoing explorative laparatomy for suspected colic neoplasm. Only histological examination allowed a correct diagnosis to be made, showing once again the considerable difficulty of differential diagnosis.
The Infections in the History of Medicine
Quinine prophylaxis in the early 20th century in malaria -affected Bologna
Sabbatani Sergio,
Sandri Antonio
The authors outline public health and environmental conditions in Italy at the end of the 19th century and the attempts made at improvement in this field. Details of health investigations carried out within the framework of the emerging State Railways are given, together with information on studies in the health and social sectors. Such investigations showed a constant connection between wetlands, malaria, and social and economic decline. Far from improving public health, political and economic policies to consolidate the nation had compounded the existing critical situation and led to a deterioration of public health and living conditions of those who, like seasonal labourers, shepherds and fishermen, lived in malarial areas. With the laws passed from 1878 onwards and especially those at the beginning of the 20th century, attempts were made - with little success - to reverse the trend with a series of palliative measures.
By contrast, outside the city gates of Bologna, where malaria epidemics had occurred between 1899 and 1901, wetland drainage, treatment of the sick and prophylaxis of healthy subjects, through the provision of quinine, achieved good results. The authors attribute such success to the fact that the population of Bologna had not become inured to the “malarial climate” which made people passive and abulic, and thus collaborated with the local administration by supporting drainage measures. The area of Bologna affected by the epidemic experienced little environmental deterioration, thereby few well-targeted measures sufficed to eradicate the epidemic.
