Identifier: TDX:632
Authors: López Dupla, Jesus Miguel
Abstract:
OF THE THESISThe thesis presented is a made up of two works that have as a common characteristic to be both a report about persistent bacteremia. The first study analyses aetiology, microbiological associations and prognosis of breakthrough bacteraemia. The second one states the characteristics of a series of infective endocarditis in a teaching hospital without cardiac surgery facilities and analyses the effect of a multidisciplinary group working at infective endocarditis. The objective of the first study is to determine the clinical significance and outcome of a large series of breakthrough bacteremia. It is a retrospective analysis of a prospectively collected database from two hospitals, hospital Clínic of Barcelona and hospital Universitari Joan XXIII of Tarragona. Patients higher than 14 years diagnosed of breakthrough bacteremia were included. Demographic characteristics, underlying diseases, origin of infection, sources of infection, microorganisms isolated, prognosis of underlying disease and mortality were analysed. Breakthrough bacteremia was detected in 392 of 6324 episodes (6,2%) of bacteremia. Eighty percent of them were nosocomial and the most frequent source of infection was endovascular. Coagulase-negative staphylococcus, S. aureus, and P. aeruginosa were the most significant microorganisms involved. The conditions independently associated with an increased risk for developing breakthrough bacteraemia were nosocomial acquisition, selected sources (central venous catheter, endocarditis and other endovascular foci), underlying conditions (neutropenia, polytraumatism, allogenic bone marrow and kidney transplantation), and some particular microbial aetiologies (S. aureus, P. aeruginosa and polymicrobial). Crude mortality rate was greater in patients with breakthrough bacteraemia, and this condition was an independent predictor of death.In conclusion, breakthrough bacteremia is an independent predictor of death and when it occurs it is mandatory to search for an endovascular focus . The objective of the second study is to assess the clinical characteristics and management of infective endocarditis at a teaching hospital without cardiac surgery facilities, before and after the introduction of a specialized team involved in the treatment of endocarditis. The study is descriptive case-control study looking at trends. The cases were collected form the hospital Universitari Joan XXIII of Tarragona. Risk factors, the rate of complications, the rate of referral for cardiac surgery, and the mortality rate were assessed, and compared with those of other tertiary hospital with cardiac surgery. The study included 120 patients, with a mean age of 50.8±17.8 years (67.6% men). Disease incidence did not change throughout the study. Fifty-five percent of infective endocarditis cases occurred in the ordinary general population, 25% were in intravenous drug users, and 20% were of nosocomial origin. The most commonly isolated microorganism was Staphylococcus aureus. Up to 83% of patients presented with a severe complication. The in-hospital mortality rate was 19.2%. Acute renal failure and perivalvular abscess were independent predictors of death. The introduction in 2002 of a multidisciplinary team involved in the diagnosis, treatment and follow-up of infective endocarditis that included a consultant cardiac surgeon, was associated with a significant increase in referrals for surgery, though in-hospital mortality was not significantly altered. In conclusion, the occurrence of acute renal failure and perivalvular abscess worsen the prognosis of infective endocarditis. The introduction of a multidisciplinary team involved in the treatment of infective endocarditis modified the management of the disease and increased referrals for cardiac surgery.Publications: Lopez Dupla M, Martínez JA, Vidal F, Almela M, López J, Marco F, Soriano A, Richart C, Mensa J. Clinical characterization of breakthrough bacteremia: a survey of 392 episodes. J Intern Med 2005; 258: 172-180.López-Dupla M, Hernández S, Olona M, Mercé J, Lorenzo A, Tapiol J, Gómez F, Santamaría J, García R, Auguet T, Richart C, Castells E, Bardají A, Vidal F. Características clínicas y evolución de la endocarditis infecciosa en una población general no seleccionada, atendida en un hospital docente que no dispone de cirugía cardiaca. Estudio de 120 casos. Rev Esp Cardiol 2006; 59: 1131-9.
Repositori URV