Strategy and technology to prevent hospital-acquired infections:Lessons from SARS,Ebola,and MERS in Asia and West Africa

Hospital-acquired infections(HAIs) are serious problems for healthcare systems, especially in developing countries where public health infrastructure and technology for infection preventions remain undeveloped. Here, we characterized how strategy and technology could be mobilized to improve the effectiveness of infection prevention and control in hospitals during the outbreaks of Ebola, Middle East respiratory syndrome(MERS), and severe acute respiratory syndrome(SARS) in Asia and West Africa. Published literature on the hospital-borne outbreaks of SARS, Ebola, and MERS in Asia and West Africa was comprehensively reviewed. The results showed that healthcare systems and hospital management in affected healthcare facilities had poor strategies and inadequate technologies and human resources for the prevention and control of HAIs, which led to increased morbidity, mortality, and unnecessary costs. We recommend that governments worldwide enforce disaster risk management, even when no outbreaks are imminent. Quarantine and ventilation functions should be taken into consideration in architectural design of hospitals and healthcare facilities. We also recommend that health authorities invest in training healthcare workers for disease outbreak response, as their preparedness is essential to reducing disaster risk.

Clinical Analysis of Hospital-acquired Bloodstream Infection in the Elderly

Objective: This study was designed to get epidemiological characteristics, etiology characteristics, prognosis assessment and prognostic factors of hospital-acquired bloodstream infection (HABSI) in the elderly in Chinese PLA General Hospital and aimed at providing a reference for HABSI in the elderly on clinical diagnosis and treatment to improve the prognosis. Methods: The clinical data and pathology data of 210 cases of the elderly patients with HABSI from 2009 to 2012 in geriatric wards were retrospectively analyzed. Compare the clinical assessment effects of APACHE-II score, SAPS-II score and SOFA score to HABSI prognosis in the elderly by plotting the receiver operating characteristic curve. Use univariate and multivariate logistic regression analysis to get prognostic factors of HABSI in the elderly. Results: Univariate analysis of mortality: Day 1 apache -> 18 II score, lung infection, invasive ventilation, chronic hepatic insufficiency, chronic renal insufficiency, substantive organ malignant tumor, deep venipuncture, indwelling gastric tube indwelling ureter, complicated with shock and acquired bloodstream infections in the elderly patients with 7 days survival state association is significant. Day- 1 SOFA score>7, chronic liver dysfunction, chronic renal insufficiency, concurrent shock, hemodialysis and 28-day survival status of patients with acquired bloodstream infection in elderly hospitals were significantly associated. Multivariate unconditioned logistic regression analysis related to death: Day-1APACHE-II score>18, parenchymal malignant tumors, and concurrent shock are independent risk factors for 7-day death in elderly patients with acquired bloodstream infection. Day-1 SOFA score>7, chronic renal insufficiency, and concurrent shock are independent risk factors for 28-day mortality in elderly patients with acquired bloodstream infection. Conclusion: The incidence of acquired bloodstream infections in the elderly was 1.37%. The 7-day and 28-day mortality rates were 8.10% and 22.38%, respectively. Concurrent shock is 26.7%. The 28- day mortality rate of concurrent shock patients was 48.21%. The best outcome score for the 7-day prognosis of elderly patients with acquired bloodstream infection was the Day-1APACHE-II score, followed by the Day-1 SOFA score. The best score for the 28-day prognostic assessment was the Day-1 SOFA score.

Surgical site infection following pancreaticoduodenectomy in a referral cancer center in Mexico

Background: Pancreaticoduodenectomy is the standard treatment for resectable periampullary cancer. Surgical site infections(SSI) are common complications with increased morbidity. The study aimed to describe the prevalence, risk factors, microbiology, and outcomes of SSI among patients undergoing pancreaticoduodenectomy. Methods: We conducted a retrospective study in a referral cancer center between January 2015 and June 2021. We analyzed baseline patient characteristics and SSI occurrence. Culture results and susceptibility patterns were described. Multivariate logistic regression was used to determine risk factors, proportional hazards model to evaluate mortality, and Kaplan-Meier analysis to assess long-term survival. Results: A total of 219 patients were enrolled in the study;101(46%) developed SSI. Independent factors for SSI were diabetes mellitus, preoperative albumin level, biliary drainage, biliary prostheses, and clinically relevant postoperative pancreatic fistula. The main pathogens were Enterobacteria and Enterococci. Multidrug-resistance rate in SSI was high but not associated with increased mortality. Infected patients had higher odds of sepsis, longer hospital stay and intensive care unit stay, and readmission rate. Neither 30-day mortality nor long-term survival was significantly different between infected and non-infected patients. Conclusions: SSI prevalence among patients undergoing pancreaticoduodenectomy was high and largely caused by resistant microorganisms. Most risk factors were related to preoperative instrumentation of the biliary tree. SSI was associated with greater risk of unfavorable outcomes;however, survival was unaffected.

Analysis of Etiology and Drug Resistance of Biliary Infections

Summary: The bile was collected from fro patients with biliary infections, with the bacterium isolated to study the sensitivity of each kind of the bacterium to several antibiotics in common use. Except G-bacterium, we also found some kinds of G+ bacterium in infection bile. G-bacterium were not sensitive to Clindamycin, G+ bacterium were sensitive to Ciprofloxacin. Escherichia coli, Xanthomonas maltophilia, Enterobacter cloacae, Pseudomonas aeruginosa were sensitive to Ampicillin. G+ bacterium were not sensitive to Azactam. Enterococcus faecalis, Enterococcus faecium, Enterobacter cloacae were not sensitive to Ceftazidime. Enterococcus faecalis, Staphylococcus coagulase negative, Staphylococcus epidermidis, Pseudomonas aeruginosa were not sensitive to Ceftriaxone Sodium. We didn't found any bacterium resistance Imipenem. The possibility of the existence of G+ bacterium as well as drug resistance should be considered n patients with biliary infections. The value of susceptibility test should be respected to avoid drug abuse of antibiotics.

Lack of association between seroprevalence of Helicobacterpylori infection and primary biliary cirrhosis

AIM:To determine the association between seroprevalence of Helicobacter pylori(H pylori)infection and primary biliary cirrhosis(PBC). METHODS:In this case-control study,149 consecutive patients(10 males,139 females,mean age 58.2±11 years, range 26-82 years)suffering from PBC and 619 consecutive healthy volunteer blood donors(523 males,96 females, mean age 47±5.3 years,range 18-65 years)attending the Hospital Blood Bank and residing in the same area were recruited.A commercial enzyme linked immunosorbent assay was used to detect anti-H pylori(IgG)antibodies in serum. RESULTS:AnUbodies to Hpyloriwere present in 78(52.3%) out of 149 PBC-patients and in 291(47%)out of 619 volunteers(P=0.24,OR 1.24,95% CI 0.85-1.80).In the subjects less than 60 years old,the prevalence of H pylori infection among PBC-patients(40/79)was slightly higher than in controls(50.6% vs 46.2%)P=0.46,OR=1.19,95% CI:0.72-1.95).In those over 60 years,the prevalence of Hpylori infection was similar between PBC-patients and controls(54.2% vs57.8%,P=0.7,OR 0.86,95% CI 0.36- 2.07). CONCLUSION:There is no association between seroprevalence of H pylori in fection and primary biliary cirrhosis.

Empirical antibiotic treatment with piperacillin-tazobactam in Patients with microbiologically-documented biliary tract infections

AIM: To report our experience with empiric antimicrobial monotherapy (piperacillin/tazobactam, of which no data are available in such specific circumstances) in microbiologically-documented infections in patients with benign and malignant conditions of the biliary tract.METHODS: Twenty-three patients, 10 with benign and 13 with malignant conditions affecting the biliary tree and microbiologically-documented infections were recruited and the efficacy of empirical antibiotic therapy was assessed.RESULTS: The two groups featured similar demographic and clinical data. Overall, the infective episodes were most due to Gram negative agents, more than 60% of such episodes (mostly in malignant conditions) were preceded by invasive instrumental maneuvers. Empirical antibiotic therapy with a single agent (piperacillin/tazobactam) was effective in more than 80% of cases. No deaths were reported following infections. CONCLUSION: An empiric therapeutic approach with piperacillin/tazobactam is highly effective in biliary tract infections due to benign or malignant conditions.

Impact of cytomegalovirus infection on biliary disease after liver transplantation-maybe an essential factor

BACKGROUND Cytomegalovirus(CMV)infection is common in liver transplant(LT)_recipients,and biliary complications occur in a large number of patients.It has been reported that CMV-DNA is more detectable in bile than in blood.AIM To investigate the effects of CMV infection on biliary complications by comparing the levels of CMV-DNA in the bile and blood of patients after LT.METHODS We conducted a retrospective analysis of 57 patients who underwent LT,10 of these patients had no biliary complications and 47 patients had biliary complications.We also compared the levels of CMV-DNA in patients’bile and blood,which were sampled concurrently.We used RNAscope technology to identify CMV in paraffin-embedded liver sections.RESULTS CMV-DNA was not detected in bile samples and was detected in 2 blood samples from patients without biliary complications.In the 47 patients with biliary complications,CMV-DNA was detected in 22 bile samples and 8 blood samples,both bile and blood samples were positive for CMV-DNA in 6 patients.The identification rate of CMV-DNA in blood was 17.0%,and was 46.8%in bile.Moreover,tissue samples from 4 patients with biliary complications tested positive using RNAscope technology but were negative with hematoxylin and eosin staining.During the follow-up period,graft failure occurred in 13 patients with biliary complications,8 of whom underwent retransplantation,and 3 died.CMV-DNA in bile was detected in 9 of 13 patients with graft failure.CONCLUSION In patients with biliary complications,the identification rate of CMV-DNA in bile was higher than that in blood.Blood CMV-DNA negative patients with biliary complications should still be monitored for CMV-related biliary tract diseases.Potential occult CMV infection may also be a contributing etiological factor in the development of graft failure.

First case of biliary Aureimonas altamirensis infection in a patient with colon cancer in China

Aureimonas altamirensis,first reported in 2006,is an aerobic,gram-negative bacillus.It is usually considered a contaminant from the surrounding environment;however,recent evidences suggest that it may be an opportunistic pathogen in humans,which may cause multiple-site infections.Here,we report the first case of biliary A.altamirensis infection in a patient with colon cancer in Guangzhou,China.The A.altamirensis strain GZ8HT01 was isolated from the bile culture taken from the patient and identified by 16S ribosomal RNA gene sequencing.Additionally,the bacterial strain was sensitive to all antibiotics tested.The patient was effectively treated with imipenem-cilastatin.These findings are valuable for the early diagnosis and effective treatment of this emerging pathogen.

Nosocomial infections and their control strategies

Nosocomial infections are also known as hospital-acquired/associated infections. National Healthcare Safety Network along with Centers for Disease Control for surveillance has classified nosocomial infection sites into 13 types with 50 infection sites, which are specific on the basis of biological and clinical criteria. The agents that are usually involved in hospitalacquired infections include Streptococcus spp., Acinetobacter spp., enterococci, Pseudomonas aeruginosa, coagulase-negative staphylococci, Staphylococcus aureus, Bacillus cereus, Legionella and Enterobacteriaceae family members, namely, Proteus mirablis, Klebsiella pneumonia, Escherichia coli, Serratia marcescens. Nosocomial pathogens can be transmitted through person to person, environment or contaminated water and food, infected individuals, contaminated healthcare personnel's skin or contact via shared items and surfaces. Mainly, multi-drug-resistant nosocomial organisms include methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Pseudomonas aeruginosa and Klebsiella pneumonia, whereas Clostridium difficile shows natural resistance. Excessive and improper use of broadspectrum antibiotics, especially in healthcare settings, is elevating nosocomial infections, which not only becomes a big health care problem but also causes great economic and production loss in the community. Nosocomial infections can be controlled by measuring and comparing the infection rates within healthcare settings and sticking to the best healthcare practices. Centers for Disease Control and Prevention provides the methodology for surveillance of nosocomial infections along with investigation of major outbreaks. By means of this surveillance, hospitals can devise a strategy comprising of infection control practices.

Predictors of Clostridium difficile infection severity in patients hospitalised in medical intensive care

AIM:To describe and analyse factors associated with Clostridium difficile infection(CDI)severity in hospitalised medical intensive care unit patients.METHODS:We performed a retrospective cohort study of 40 patients with CDI in a medical intensive care unit(MICU)at a French university hospital.We include patients hospitalised between January 1,2007and December 31,2011.Data on demographics characteristics,past medical history,CDI description was collected.Exposure to risk factors associated with CDI within 8 wk before CDI was recorded,including previous hospitalisation,nursing home residency,antibiotics,antisecretory drugs,and surgical procedures.RESULTS:All included cases had their first episode of CDI.The mean incidence rate was 12.94 cases/1000admitted patients,and 14.93,8.52,13.24,19.70,and8.31 respectively per 1000 admitted patients annually from 2007 to 2011.Median age was 62.9[interquartile range(IQR)55.4-72.40]years,and 13(32.5%)were women.Median length of MICU stay was 14.0d(IQR 5.0-22.8).In addition to diarrhoea,the clinical symptoms of CDI were fever(>38℃)in 23 patients,abdominal pain in 15 patients,and ileus in 1 patient.The duration of diarrhoea was 13.0(8.0-19.5)d.In addition to diarrhoea,the clinical symptoms of CDI were fever(>38℃)in 23 patients,abdominal pain in 15 patients,and ileus in 1 patient.Prior to CDI,38patients(95.0%)were exposed to antibiotics,and 12(30%)received at least 4 antibiotics.Fluoroquinolones,3rdgeneration cephalosporins,coamoxiclav and tazocillin were prescribed most frequently(65%,55%,40%and 37.5%,respectively).The majority of cases were hospital-acquired(n=36,90%),with 5 cases(13.9%)being MICU-acquired.Fifteen patients had severe CDI.The crude mortality rate within 30 d after diagnosis was 40%(n=16),with 9 deaths(9 over 16;56.3%)related to CDI.Of our 40 patients,15(37.5%)had severe CDI.Multivariate logistic regression showed that male gender[odds ratio(OR):8.45;95%CI:1.06-67.16,P=0.044],rising serum C-reactive protein levels(OR=1.11;95%CI:1.02-1.21,P=0.021),and previous exposure to fluoroquinolones(OR=9.29;95%CI:1.16-74.284,P=0.036)were independently associated with severe CDI.CONCLUSION:We report predictors of severe CDI not dependent on time of assessment.Such factors could help in the development of a quantitative score in ICU’s patients.

Bacterial co-infection in patients with SARS-CoV-2 in the Kingdom of Bahrain

BACKGROUND The coronavirus disease 2019(COVID-19)pandemic presents a significant challenge to the medical profession,increasing in the presence of microbial coinfection.Bacterial and Fungal co-infections increase the risk of morbidity and mortality in patients with COVID-19.AIM To study the bacterial profile in patients with COVID-19 who needed admission to receive treatment in the main centres concerned with managing COVID-19 disease in the Kingdom of Bahrain.METHODS The study was a retrospective observational analysis of the bacterial profile and the bacterial resistance in patients with confirmed COVID-19 disease who needed admission to receive treatment in the main centres assigned to manage patients with COVID-19 disease in the Kingdom of Bahrain from February to October 2020.We used the electronic patients’records and the microbiology laboratory data to identify patients’demographics,clinical data,microbial profile,hospital or community-acquired,and the outcomes.RESULTS The study included 1380 patients admitted with confirmed COVID-19 disease during the study period.51%were admitted from February to June,and 49%were admitted from July to October 2020,with a recurrence rate was 0.36%.There was a significant increase in bacterial and fungal co-infection in the second period compared to the first period.The most common isolated organisms were the gram-negative bacteria(mainly Klebsiella pneumoniae,Pseudomonas aeruginosa,multi-drug resistant Acinetobacter baumannii,and Escherichia coli),the grampositive bacteria(mainly coagulase negative Staphylococci,Enterococcus faecium,Enterococcus faecalis,Staphylococcus aureus)and fungaemia(Candida galabrata,Candida tropicalis,Candida albicans,Aspergillus fumigatus,Candida parapsilosis,Aspergillus niger).The hospital-acquired infection formed 73.8%,61.6%,100%gram-negative,gram-positive and fungaemia.Most of the hospital-acquired infection occurred in the second period with a higher death rate than communityacquired infections.CONCLUSION Bacterial and fungal co-infections in patients admitted with confirmed COVID-19 disease pose higher morbidity and mortality risks than those without coinfections.We should perform every effort to minimize these risks.

Status and Progress in the Control of Infection in Chinese Hospitals

This paper summarizes the characteristics and control of hospital-wide infections as identified by domestic surveys and research studies. This review also provides references to establish the basis for the control and management of hospital-acquired infection. Hospitalacquired infections are mainly initiated by Gram-negative bacteria and mainly localize in the lower respiratory tracts of patients. The intensive care unit has the highest infection rate among all hospital departments. Infants and the elderly are the most susceptible groups of patients to infection. Hands are an important route of pathogen transmission. The abuse of antibacterial drugs is an important factor of hospital-acquired infection. To control hospital-acquired infections, a sound management system should be established. In addition, medical staff, especially newcomers and interns, must receive strengthened training to improve their knowledge of hospital-acquired infection. Hand hygiene and the rational use of antibacterial drugs should be emphasized.

A case of methicillin-resistant Staphylococcus aureus infection following bile duct stenting

AIM: To present a case of methicillin-resistant Staphylococcus aureus (MRSA) infection following bile duct stenting in a patient with malignant biliary obstruction.METHODS: A 78-year-old male patient was admitted to a community hospital with progredient painless jaundice lasting over two weeks, weight loss and sweating at night.Whether a stent should be implanted pre-operatively in jaundiced patients or whether these patients should directly undergo surgical resection, was discussed.RESULTS: ERC and a biopsy from the papilla of Vater revealed an adenocarcinoma. In addition, a 7-Ch plastic stent was placed into the common bile duct. Persistent abdominal pain, increasing jaundice, weakness and indigestion led to the transfer of the patient to our hospital.A pylorus-preserving pancreatoduodenectomy wasperformed. Intraoperatively, bile leaked out of the transected choledochus andthe stent was found to be dislocated in the duodenum. A smear of the bile revealed an infection with MRSA, leading to post-operative isolation of the patient.CONCLUSION:As biliary stents can cause severe infection of the bile, the need for pre-operative placement of biliary stents should be carefully evaluated in each individual case.

Chlamydia pneumoniae replicates in Kupffer cells in mouse model of liver infection

AIM: To develop an animal model of liver infection with Chlamydia pneumoniae (C. pneumoniae) in intraperito-neally infected mice for studying the presence of chlamy-diae in Kupffer cells and hepatocytes.METHODS: A total of 80 BALB/c mice were inoculated intraperitoneally with C. pneumoniae and sacrificed at various time points after infection. Chlamydiae were looked for in liver homogenates as well as in Kupffer cells and hepatocytes separated by liver perfusion with collagenase. C. pneumoniae was detected by both isola-tion in LLC-MK2 cells and fluorescence in situ hybridiza-tion (FISH). The releasing of TNFA-α by C. pneumoniae in vitro stimulated Kupffer cells was studied by enzyme-linked immunosorbent assay.RESULTS: C. pneumoniae isolation from liver homoge-nates reached a plateau on d 7 after infection when 6 of 10 animals were positive, then decreased, and became negative by d 20. C. pneumoniae isolation from sepa-rated Kupffer cells reached a plateau on d 7 when 5 of 10 animals were positive, and became negative by d 20. The detection of C. pneumoniae in separated Kupffer cells by FISH, confirmed the results obtained by culture. Isolated hepatocytes were always negative. Stimula-tion of Kupffer cells by alive C. pneumoniae elicited high TNF-α levels. CONCLUSION: A productive infection by C. pneumo-niae may take place in Kupffer cells and C. pneumoniae induces a local pro-inflammatory activity. C. pneumoniae is therefore, able to act as antigenic stimulus when local-ized in the liver. One could speculate that C. pneumoniaeinfection, involving cells of the innate immunity such as Kupffer cells, could also trigger pathological immune re-actions involving the liver, as observed in human patients with primary biliary cirrhosis.

Liver involvement in patients with COVID-19 infection:A comprehensive overview of diagnostic imaging features

During the first wave of the pandemic,coronavirus disease 2019(COVID-19)infection has been considered mainly as a pulmonary infection.However,different clinical and radiological manifestations were observed over time,including involvement of abdominal organs.Nowadays,the liver is considered one of the main affected abdominal organs.Hepatic involvement may be caused by either a direct damage by the virus or an indirect damage related to COVID-19 induced thrombosis or to the use of different drugs.After clinical assessment,radiology plays a key role in the evaluation of liver involvement.Ultrasonography(US),computed tomography(CT)and magnetic resonance imaging(MRI)may be used to evaluate liver involvement.US is widely available and it is considered the first-line technique to assess liver involvement in COVID-19 infection,in particular liver steatosis and portal-vein thrombosis.CT and MRI are used as second-and third-line techniques,respectively,considering their higher sensitivity and specificity compared to US for assessment of both parenchyma and vascularization.This review aims to the spectrum of COVID-19 liver involvement and the most common imaging features of COVID-19 liver damage.

Aeromonas veronii biovar veronii and sepsis-infrequent complication of biliary drainage placement: A case report

BACKGROUND Aeromonas species are uncommon pathogens in biliary sepsis and cause substantial mortality in patients with impaired hepatobiliary function. Asia has the highest incidence of infection from Aeromonas,whereas cases in the west are rare.CASE SUMMARY We report the case of a 64-year-old woman with advanced pancreatic cancer and jaundice who manifested fever,abdominal pain,severe thrombocytopenia,anemia and kidney failure following the insertion of a percutaneous transhepatic biliary drainage. Blood culture results revealed the presence of Aeromonas veronii biovar veronii(A. veronii biovar veronii). After antibiotic therapy and transfusions,the life-threatening clinical conditions of the patient improved and she was discharged.CONCLUSION This was a rare case of infection,probably the first to be reported in West countries,caused by A. veronii biovar veronii following biliary drainage. A finding of Aeromonas must alert clinician to the possibility of severe sepsis.

Is osteoporosis a peculiar association with primary biliary cirrhosis?

AIM： （1） To compare the prevalence of osteoporosis （t-score ≤-2.5 SD） between stage IV PBC patients, and two groups of age- and sex-matched controls： one with hepatitis C virus （HCV）-related cirrhosis, and the other one consisting of a group of healthy subjects from the general population, （2） to identify the main risk factors for the development of bone loss. METHODS： Thirty-five stage IV PBC patients （mean age 52.5±10 years）, 49 females with HCV-related cirrhosis （mean age 52.9±5.8 years） and 33 healthy females （mean age 51.8±2.22 years） were enrolled in the study. Bone metabolism was evaluated by measuring serum calcium corrected for serum albumin （Ca corr.）, 25-hydroxy vitamin D （25-OH vit D）, parathyroid hormone, osteocaldn. Bone mineral density （BMD） was assessed at the lumbar spine by dual-photon X-ray absorptiometry. RESULTS： Osteoporosis was present in 5/35 PBC patients （14.2%） and in 7/49 HCV-related drrhotic patients （14.3%）, without any statistical difference between the two groups. Among healthy control subjects, none had osteoporosis. No difference was found between the three groups in serum parameters of bone metabolism. Univariate analysis showed that menopausal state and low BMI were significantly correlated with osteoporosis. Multivariate regression analysis showed that menopausal status, BMI〈23, and old age were independent variables significantly correlated with osteoporosis. CONCLUSION： PBC in itself has no negative influence on BMD. End-stage liver disease patients carry a disease-specific risk for osteoporosis, but have an effective risk of bone loss in relation to individual potential risk for each patient. A practical message should be taken into account, that is, every effort should be made to prevent osteoporosis when a patient has simple osteopenia, or if it is a woman in or near menopausal age.

Negative short-term impact of intraoperative biliary lavage in patients with hepatolithiasis

AIM: To evaluate short-term outcomes following intraoperative biliary lavage for hepatolithiasis.METHODS: A total of 932 patients who were admitted to the West China Medical Center of Sichuan University between January 2010 and January 2014 and underwent bile duct exploration and lithotomy were retrospectively included in our study. The patients were divided into the lavage group and the control group. Related pre-, intra-, and postoperative factors were recorded, analyzed, and compared between the two groups in order to verify the effects of biliary lavage on the short-term outcome of patients with hepatolithiasis. RESULTS: Amongst the patients who were included, 678 patients with hepatolithiasis were included in the lavage group, and the other 254 patients were enrolled in the control group. Data analyses revealed that preoperative baseline and related intraoperative variables were not significantly different. However, patients who underwent intraoperative biliary lavage had prolonged postoperative hospital stays(6.67 d vs 7.82 d, P = 0.024), higher hospitalization fees(RMB 28437.1 vs RMB 32264.2, P = 0.043), higher positive rates of bacterial cultures from blood(13.3% vs 25.8%, P = 0.001) and bile(23.6% vs 40.7%, P= 0.001) samples, and increased usage of advanced antibiotics(26.3% vs 38.2%, P = 0.001). In addition, in the lavage group, more patients had fever(> 37.5℃, 81.4% vs 91.1%, P = 0.001) and hyperthermia(> 38.5℃,39.7% vs 54.9%, P = 0.001), and higher white blood cell counts within 7 d after the operation compared to the control group.CONCLUSION: Intraoperative biliary lavage might increase the risk of postoperative infection, while not significantly increasing gallstone removal rate.

Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis

AIM:To develop an algorithm to improve the diagnosis and treatment of patients with biliary candidiasis.METHODS:We performed a prospective study of 127patients who underwent endoscopic retrograde cholangiopancreatography,for various biliary disorders,at 3 tertiary referral centers in Germany from July 2011through July 2012(ClinicalTrials.gov:NCT01109550).Bile,buccal,and stool samples were collected.When indicated,endoscopic transpapillary bile duct biopsies were performed to clarify the etiology of bile duct strictures and to prove invasive fungal infections.RESULTS:Candida species were detected in 38 of the 127 bile samples(29.9%).By multivariate analysis patients’age and previous endoscopic sphincterotomy were independent risk factors for biliary candidiasis(P<0.05).Patients with immunosuppression(P=0.058)and recent long-term antibiotic therapy(>7 d)(P=0.089)tend to be at risk for biliary candidiasis.One patient was negative in mycological culture of bile fluid but invasive biliary candidiasis was diagnosed histologically.Of Candida subspecies detected,36.7%were azole-resistant,such as C glabrata.Eight patients received anti-mycotic therapy,based on our algorithm.Of these,3 had cancer with biliary tract involvement,2had secondary sclerosing cholangitis,1 had retroperitoneal fibrosis,and 5 had septicemia.In all patients contamination was ruled out by smears of the endoscope channel.CONCLUSION:Gastroenterologists should be aware of frequent candida colonization in patients with cholangitis and biliary disorders.Our suggested algorithm facilitates the further clinical management.

Thyroid storm precipitated by acute biliary pancreatitis

Thyroid storm is an acute, life-threatening exacerbation and sudden releasing large amounts of thyroid hormone in a short period of time. Nevertheless, critical aggravation of hyperthyroidism typically resulted from concurrent disorder. Synchronous management of thyroid storm along with its precipitant, such as infection is recommended. We described the case of an acute biliary pancreatitis complicated with a thyroid storm. The patient was successfully managed with a quick surgical intervention and further critical care for thyroid storm. Although it is widely believed that pancreatitis is seldom concurrent with thyrotoxicosis, thyroid storm can be precipitated by a variety of factors, including intra-abdominal infections such as acute pancreatitis or perforated peptic ulcer. In conclusion, acute pancreatitis in patients with thyrotoxicosis seems to be extremely rare, but such patients should be managed intensively against underlying thyroid disorders as well as pancreatitis.