JAMA Surgery May 3, 2017

Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017

Berríos-Torres SI et al.

Importance 

The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies.

Objective 

To provide new and updated evidence-based recommendations for the prevention of SSI.

Evidence Review 

A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5487 potentially relevant studies identified in literature searches, 5759 titles and abstracts were screened, and 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence, evaluated, and categorized.

Findings 

Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI.

Conclusions and Relevance

This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

 

FULL TEXT

http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725

PDF (CLIC en “DOWNLOAD PDF”)

May 27, 2017 at 10:42 am

An evaluation of automated chest radiography reading software for tuberculosis screening among public- and private-sector patients

Eur Respir J ERJ May 2017 V.49 N.5

Md Toufiq Rahman, Andrew J. Codlin, Md Mahfuzur Rahman, Ayenun Nahar, Mehdi Reja, Tariqul Islam, Zhi Zhen Qin, Md Abdus Shakur Khan, Sayera Banu, and Jacob Creswell

Computer-aided reading (CAR) of medical images is becoming increasingly common, but few studies exist for CAR in tuberculosis (TB). We designed a prospective study evaluating CAR for chest radiography (CXR) as a triage tool before Xpert MTB/RIF (Xpert).

Consecutively enrolled adults in Dhaka, Bangladesh, with TB symptoms received CXR and Xpert. Each image was scored by CAR and graded by a radiologist. We compared CAR with the radiologist for sensitivity and specificity, area under the receiver operating characteristic curve (AUC), and calculated the potential Xpert tests saved.

A total of 18 036 individuals were enrolled. TB prevalence by Xpert was 15%. The radiologist graded 49% of CXRs as abnormal, resulting in 91% sensitivity and 58% specificity. At a similar sensitivity, CAR had a lower specificity (41%), saving fewer (36%) Xpert tests. The AUC for CAR was 0.74 (95% CI 0.73–0.75). CAR performance declined with increasing age. The radiologist grading was superior across all sub-analyses.

Using CAR can save Xpert tests, but the radiologist’s specificity was superior. Differentiated CAR thresholds may be required for different populations. Access to, and costs of, human readers must be considered when deciding to use CAR software. More studies are needed to evaluate CAR using different screening approaches.

FULL TEXT

http://erj.ersjournals.com/content/49/5/1602159?etoc

PDF

http://erj.ersjournals.com/content/erj/49/5/1602159.full.pdf

May 27, 2017 at 8:36 am

Nueva GUIA emitida por CDC sobre las pruebas de IgM contra el virus de Zika en el embarazo

por Janis C. Kelly

12/05/2017 – Centers for Disease Control and Prevention (CDC) de Estados Unidos actualizó el 5 de mayo las recomendaciones para los médicos que atienden a mujeres embarazadas asintomáticas con posible exposición al zika.[1]

La guía actualizada incorpora nuevos datos que muestran que la respuesta de inmunoglobulina M (IgM) al virus de Zika puede persistir durante más de 12 semanas y por tanto no es un signo fiable de infección reciente. Por el contrario, la positividad en la prueba de ácido nucleico (NAT) del virus de Zika se desvanece con el tiempo a medida que disminuye el nivel de ARN de zika, de manera que una prueba de ácido nucleico negativa no descarta una infección reciente.

“Este cambio se está haciendo debido a que la guía sobre las pruebas de zika de CDC en mujeres embarazadas se basa, en parte, en una prueba [Zika mediante ELISA IgM] para detectar anticuerpos contra el virus de Zika o proteínas que el cuerpo elabora para combatir las infecciones por el virus de Zika”, de acuerdo con un nuevo comunicado de CDC.[2] “Nuevos datos parecen indicar que la infección por el virus de Zika, similar a algunas otras infecciones por flavivirus, puede hacer que los anticuerpos contra el virus de Zika permanezcan en el cuerpo durante meses después de la infección en algunos individuos. En consecuencia, es posible que los resultados de estas pruebas no puedan determinar si las mujeres se infectaron antes o después de su embarazo”.

La determinación del tiempo de infección es importante pues el riesgo para el feto es más alto con la infección durante el primer trimestre del embarazo.

La guía actualizada modifica las recomendaciones para las pruebas de las mujeres embarazadas asintomáticas que podrían haber tenido exposición al virus de Zika antes de la concepción. Las recomendaciones para las pruebas en mujeres embarazadas que tienen síntomas de infección por virus de Zika permanecen sin cambio.

“Sin embargo”, advierte el comunicado de CDC, “si una mujer embarazada sintomática tiene positividad para IgM y negatividad para la prueba de ácido nucleico, y ha vivido o viajado a una zona con un aviso preventivo de viaje por reporte de casos de zika publicada por CDC (https://wwwnc.cdc.gov/travel/page/zika-travel-information), los profesionales sanitarios deben reconocer que el resultado positivo para IgM no necesariamente indica infección reciente”.

Cinco pasos para evaluar a mujeres embarazadas asintomáticas

CDC recomienda cinco pasos para valorar a las mujeres embarazadas asintomáticas con posible exposición al virus de Zika antes de la concepción, como las que han vivido o que han viajado con frecuencia (diariamente o cada semana) a zonas con aviso preventivo de viaje del CDC.

Efectuar detección de riesgo de exposición y síntomas de zika en todas las mujeres embarazadas, con prueba de ácido nucleico del virus de Zika de inmediato en quienes presentaron síntomas durante el embarazo o cuya pareja sexual tuvo positividad en las pruebas para infección por virus de Zika.

Evaluar de manera trimestral mediante la prueba de ácido nucleico del virus de Zika, a no ser que una prueba previa fuese positiva.

Si se llevó a cabo amniocentesis por un motivo diferente a infección por virus de Zika, tomar en cuenta también llevar a cabo una prueba de ácido nucleico del virus de Zika en especímenes de amniocentesis.

Asesorar de manera trimestral a las mujeres embarazadas sobre las limitaciones de la prueba de IgM para virus de Zika y la prueba de ácido nucleico.

Considerar las pruebas de IgM previas a la concepción con el fin de determinar las concentraciones de IgM para el virus de Zika iniciales como parte de la asesoría previa a la concepción.

La infección por virus de Zika en una mujer embarazada conlleva un aumento en el riesgo para el feto, pero la guía actualizada de CDC hace notar que las respuestas prolongadas de IgM para el virus de Zika, al igual que en otras infecciones por flavivirus, complican los esfuerzos para distinguir las infecciones recientes de las previas en zonas con transmisión endémica. Puede ser más difícil establecer la temporalidad de la infección por la reacción cruzada con otros flavivirus, sobre todo dengue.

Datos de estudios de casos confirmados de Zika, mediante la prueba de ácido nucleico en pacientes sintomáticas en Puerto Rico, en donde el dengue no es un factor, revelaron una mediana de tiempo transcurrido hasta la primera IgM negativa de 122 días después del inicio de los síntomas (rango: 8 días – 210 días). Las pruebas de ácido nucleico en estas pacientes demostraron ARN del virus en 36% de las pacientes 8 a 15 días después del inicio de los síntomas, pero tres de cinco mujeres embarazadas en ese estudio tuvieron ARN detectable a los 46 días y una a los 80 días después del inicio de los síntomas.

“Nuestra guía actual es parte de un esfuerzo continuado por compartir datos lo más pronto posible para acciones de salud pública”, agregó en el comunicado de prensa el Dr. Henry Walke, gerente de incidentes de las iniciativas de respuesta al virus de Zika en CDC. “A medida que sabemos más sobre las limitaciones de las pruebas de anticuerpos, seguimos actualizando nuestra guía para garantizar que los profesionales sanitarios cuenten con la información más actualizada para asesorar a las pacientes que se infectan por virus de Zika durante el embarazo”.

Referencias

1-CDC Health Alert Network (HAN). Prolonged IgM Antibody Response in People Infected with Zika Virus: Implications for Interpreting Serologic Testing Results for Pregnant Women. Health Advisory 402. 5 May 2017. Guía

2-Centers for Disease Control and Prevention (CDC). CDC updates guidance on interpretation of Zika testing results for pregnant women. Press Release. 5 May 2017. Comunicado

MEDSCAPE SOURCE

http://espanol.medscape.com/verarticulo/5901495?nlid=114402_4169&src=WNL_esmdpls_170517_mscpedit_infd&uac=54104DR&impID=1349777&faf=1

May 19, 2017 at 8:00 am

¡ADIOS QUERIDO MAESTRO! ¡ADIOS QUERIDO Dr. Franciso “Paco” Maglio!

Dr. Francisco “Paco” MAGLIO

24/04/1935 – 17/05/2017

¡ADIOS QUERIDO MAESTRO! ¡ADIOS QUERIDO Dr. Franciso “Paco” Maglio!

Se ha ido uno de los más grandes médicos argentinos, el entrañable Paco Maglio.

Su herencia vivirá en cada uno de nosotros para siempre ….

 

El colega y amigo Dr. Daniel Flichtentrei escribió los siguiente en INTRAMED:

“No se puede escribir consternado por el dolor de la pérdida. Pero tampoco se puede callar cuando se va el más grande de todos.

Paco querido, te despedimos estremecidos, desolados, entre la memoria de tus palabras vivas y el compromiso de seguir siendo fieles a todo lo que nos hiciste ver durante tantos años.

Cuando nos amenazaba el olvido de lo que nos hizo médicos, cuando todo se hacía una triste aritmética del sufrimiento humano; apareció tu voz luminosa para sacudirnos como un padre firme y cariñoso.

Me guardo para siempre algunas madrugadas heladas conversando sobre el raro privilegio de la medicina y acerca de la felicidad inmensa de poder ayudar al otro. Tus charlas, tus libros, tu mano pesada sobre mi espalda y la filosofia cruel de tus tangos amados.

No habrá forma de agradecerte lo que no tiene precio. No hay modo de devolverte nada de lo que nos has dado. Somos mejores, esa es tu obra.

Cada vez que la profesión se ocurece por la indignidad o se pierde arrastrada por el flujo incontrolable de la trivialidad o el poder de los mercenarios, tu figura se agiganta.

Te queremos mucho, y siempre te querremos en tiempo presente. Así, como esta noche maldita de otoño en la que la eternidad nos quita tu cuerpo pero nos deja tu espíritu metido muy adentro de cada uno de nosotros.

Hoy a muerto mi padre por segunda vez. Hasta siempre y gracias, viejo querido. ¡Adios Paco!

May 18, 2017 at 3:42 pm

Chronic active Epstein–Barr virus infection associated with hemophagocytic syndrome and extra-nodal natural killer/T-cell lymphoma in an 18-year-old girl: A case report

MEDICINE May 2015 V.96 N.19 P.e6845

Xing, Yawei; Yang, Junwen; Lian, Guanghui; Chen, Shuijiao; Chen, Linlin; Li, Fujun

Rationale:

Chronic active Epstein–Barr virus infection (CAEBV) associated with hemophagocytic syndrome (HPS) and extra-nodal natural killer (NK)/T-cell lymphoma (ENKL) is a rare life-threatening disorder. This disease is easily misdiagnosed because of its varied presentations.

Patient concerns:

An 18-year-old girl was admitted to our hospital with a history of edema in the lower limbs and intermittent fever lasting for more than 1 month. At admission, she had severe liver injury of unknown etiology. Laboratory test results revealed pancytopenia, hyperferritinemia, hypertriglyceridemia, and hypofibrinogenemia. Results of serologic tests for EBV were positive. Results of a skin biopsy indicated EBV-positive NK/T-cell lymphoma, and bone marrow aspiration revealed focal hemophagocytosis and atypical lymphoid cells.

Diagnosis:

On the basis of these findings, we diagnosed the case as extra-nodal NK/T-cell lymphoma-associated HPS (natural killer/T-cell lymphoma-associated hemophagocytic syndrome), which is commonly induced by CAEBV.

Interventions:

Treatment consisted of general management of hepatitis, supplemented with albumin and empirical antibiotic therapy.

Outcomes:

The patient died from massive gastrointestinal hemorrhage a week after she was discharged from the hospital.

Lessons:

ENKL and HPS present with varied features and are generally fatal; therefore, clinicians should proceed with caution in suspected cases. HPS should be considered when the patient presents with fever, hepatosplenomegaly, pancytopenia, and liver failure. When HPS is suspected, clinicians should determine the underlying cause, such as severe infection, including infection with viruses such as EBV; genetic predisposition; or underlying malignancies, especially lymphoma because of its strong association with HPS.

FULL TEXT

http://journals.lww.com/md-journal/Fulltext/2017/05120/Chronic_active_Epstein_Barr_virus_infection.38.aspx

PDF (download haciendo CLIC en “Article as PDF”)

 

May 12, 2017 at 3:35 pm

Decolonization in Prevention of Health Care-Associated Infections.

Clin Microbiol Rev. April 2016 V.29 N.2 P.201-22.

Septimus EJ1, Schweizer ML2.

Author information

1 Hospital Corporation of America, Nashville, Tennessee, USA Texas A&M Health Science Center, College of Medicine, Houston, Texas, USA Edward.septimus@hcahealthcare.com.

2 University of Iowa Carver College of Medicine, Iowa City, Iowa, USA Iowa City VA Health Care System, Iowa City, Iowa, USA University of Iowa College of Public Health, Iowa City, Iowa, USA.

Abstract

Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection.

Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs).

This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant.

Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin.

Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin.

Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy.

Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida.

Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time.

There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms.

The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.

PDF

http://cmr.asm.org/content/29/2/201.full.pdf+html

May 12, 2017 at 7:45 am

Quantification of circulating Mycobacterium tuberculosis antigen peptides allows rapid diagnosis of active disease and treatment monitoring.

Proc Natl Acad Sci USA. Apr 11, 2017 V.114 N.15 P.3969-3974.

Liu C1,2,3, Zhao Z4, Fan J1,3, Lyon CJ1,3, Wu HJ1,5, Nedelkov D6, Zelazny AM4, Olivier KN7, Cazares LH8, Holland SM9, Graviss EA10, Hu Y11,2,3.

Author information

1 Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030.

2 School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ 85287.

3 Virginia G. Piper Biodesign Center for Personalized Diagnostics, The Biodesign Institute, Arizona State University, Tempe, AZ 85287.

4 Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892.

5 Department of Chemical Engineering, Texas A&M University, College Station, TX 77843.

6 Molecular Biomarkers Laboratory, The Biodesign Institute, Arizona State University, Tempe, AZ 85287.

7 Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD 20892.

8 Molecular and Translational Sciences, US Army Medical Research Institute of Infectious Diseases, Frederick, MD 21702.

9 Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892.

10 Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX 77030.

11 Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030; tyhu@asu.edu.

Abstract

Tuberculosis (TB) is a major global health threat, resulting in an urgent unmet need for a rapid, non-sputum-based quantitative test to detect active Mycobacterium tuberculosis (Mtb) infections in clinically diverse populations and quickly assess Mtb treatment responses for emerging drug-resistant strains. We have identified Mtb-specific peptide fragments and developed a method to rapidly quantify their serum concentrations, using antibody-labeled and energy-focusing porous discoidal silicon nanoparticles (nanodisks) and high-throughput mass spectrometry (MS) to enhance sensitivity and specificity. NanoDisk-MS diagnosed active Mtb cases with high sensitivity and specificity in a case-control study with cohorts reflecting the complexity of clinical practice. Similar robust sensitivities were obtained for cases of culture-positive pulmonary TB (PTB; 91.3%) and extrapulmonary TB (EPTB; 92.3%), and the sensitivities obtained for culture-negative PTB (82.4%) and EPTB (75.0%) in HIV-positive patients significantly outperformed those reported for other available assays. NanoDisk-MS also exhibited high specificity (87.1-100%) in both healthy and high-risk groups. Absolute quantification of serum Mtb antigen concentration was informative in assessing responses to antimycobacterial treatment. Thus, a NanoDisk-MS assay approach could significantly improve the diagnosis and management of active TB cases, and perhaps other infectious diseases as well.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393254/pdf/pnas.201621360.pdf

May 11, 2017 at 11:28 am

Older Posts


Categories

  • Feeds RSS

  • Feeds