The 759 cases of brain death declaration (BDD [Italian law, 6 hours of observation time]) that occurred in 190 Italian intensive care units (ICUs) between May and September 2012 were studied to quantify carbapenem-resistant gram-negative bacteria (CR-GN) isolated in organ donors, to evaluate adherence to national screening guidelines, and to identify risk factors for CR-GN isolation. Mandatory blood, bronchoalveolar lavage, and urine cultures were performed on the BDD day in 99% of used donors. Because results were rarely made available before transplant, >20% of transplants were performed before obtaining any microbiological information, and organs from 15 of 22 CR-GN cases were used. Two (lung-liver) of the 37 recipients died, likely because of donor-derived early CR-GN sepsis. ICU stay >3 days (odds ratio [OR] = 7.49, P = .004), fever (OR = 3.11, P = .04), age <60 years (OR = 2.80, P = .06), and positive ICU epidemiology (OR = 8.77, P = .07) were associated with CR-GN isolation. An association between single ICU and risk of CR-GN was observed, as a result of differences across ICUs (ICC = 29%; 95% confidence interval [CI] 6.5%-72%) probably related to inadequate practices of infection control. Continuous education aimed at implementing priority actions, including stewardship programs for a rational use of antimicrobials, is a priority in healthcare systems and transplant networks. Improved awareness among ICU personnel regarding the importance of early CR-GN detection and timely alert systems might facilitate decisions regarding organ suitability and eventually save recipient lives.
The Guidelines of the surgical management of severe head injury in adults, as evolved by the Neurotraumatology Group of the Italian Neurosurgery Society and the Italian Society for Anaesthesia, Analgesia, Reanimation and Intensive Care are presented and briefly discussed. Guidelines presented here are of a pragmatic nature, based on consensus and expert opinion. Aspects pertaining to specific indications to surgery and/or to the possibility of conservative management of different traumatic intracranial lesions are highlighted. The importance of surgery in preventing secondary insults to the traumatised brain is emphasised.
In patients with SLE dsDNA binding activity, C3 and C4 levels are correlated with the clinical course of the nephritis. In fact the study of these serological parameters has a prognostic value in patients treated with methylprednisolone pulse therapy. This treatment can rapidly normalize an acute phase.
Background: Organ shortage represents an obstacle preventing further increase of transplantation in KSA. In this framework, in late 2017 the Ministry of Health launched a 3-year project coordinated by DTI Foundation with the support of the SCOT (Saudi Center for Organ Transplantation) aiming to improve the donation rates by implementing an organ donation quality system based on the most successful models in organ donation (SEUSA) and quality indicators (ODEQUS). Methods: The present study compares the organ donation critical pathway in four Saudi hospitals between 2017 (no quality program) Vs. 2018 (quality program implementation). The participant hospitals were selected considering their existing donation and transplantation programs and organ donation potentiality. The first year of the project included a diagnosis study to achieve a comprehensive vision of the current situation; a monthly registry to detect possible brain death patients in the hospitals; monthly videocalls to analyze the data collected lead by organ donation experts; an external audit per hospital in the 6th month to evaluate the implementation. The diagnosis study was divided in two actions, and adaptation of the ODDS (Organ Donation Diagnosis Survey) and “in situ” visits. Results: The diagnosis study allowed to identify the organizational, structural and educational needs and to foresee solutions. The visits were essential to complete the evaluation and make recommendations: to create an in-hospital team to identify possible donors; to encourage the participation of the treating doctor in the family interview; to adapt the protocols; to promote continuous training; to promote the D&T public awareness and visibility. The possible donation alerts have increased from 100 in 2017 to 298 in 2018. 250 potential, 101 eligible and 26 actual donors have been registered during the project implementation. An increase in the possible donor detection (198%) and the potential donor referral (207%) has been identified, plus a 54% in eligible donors and a 44% in donation rate. Conclusions: The implementation of a quality system has allowed an improvement of the donation program, which can also be reflected in the donation rates of the evaluated hospitals. Moreover, the program has been useful to stablish the donor detection and audit methodologies and to identify weak spots. Overall, in-hospital protocols have been reviewed and refined, specifically regarding brain death diagnosis and donor maintenance. References: 1. F. Delmonico, B. Domínguez-Gil, R. Matesanz, L. Noel, A call for government accountability to achieve national self-sufficiency in organ donation and transplantation. The Lancet. 2011;378: 1414-1418 2. Third WHO Global Consultation on Organ Donation and Transplantation: striving to achieve self-sufficiency, March 23-25, 2010, Madrid, Spain. Transplantation. 2011 Jun15;91 Suppl 11:S27-8 3. Manyalich M, et al. SEUSA. Transplantation Proceedings. 2015;47: 2328-2331 4. Domínguez-Gil B, Delmonico F.L, Matesanz R, O’Connor K, Minina M, Muller E, Young K, Manyalich M, Chapman J, Kirste G, Al-Mousawi M, Coene L, García V.D, Gautier S, Hasegawa T, Jha V, Kwek T.K, Chen Z.K, Costa A.N, Nathan H.M, Ploeg R, Reznik O, Rosendale J.D, Tibell A, Tsoulfas G, Vathsala A and Noël L. The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation. Transplantation International. 2011; apr;24(4):373-8. 5. E. Arredondo, M. López-Fraga, E. Chatzixiros, B. Senemaud, P. Brezovsky, C. Carella, C. Ballesté, A. Aydin Mehmet, G. Tomadze, I. Codreanu, A.A. Sarkissian, M. Simeonova, A. Nikonenko, V. Zota, M.P. Gómez, M. Manyalich, C. Bolotinha, A. Franca, A.N. Costa, M.-O. Ott, and K.-H. Buchheit. Council of Europe Black Sea Area Project: International Cooperation for the Development of Activities Related to Donation and Transplantation of Organs in the Region. Transplantation Proceedings. 2018; 50: 374-381
Background Bacterial infections remain a challenge to solid organ transplantation. Due to the alarming spread of carbapenem-resistant gram negative bacteria, these organisms have been frequently recognized as cause of severe infections in solid organ transplant recipients. Methods and Findings Between 15 May and 30 September 2012 we enrolled 887 solid organ transplant recipients in Italy with the aim to describe the epidemiology of gram negative bacteria spreading, to explore potential risk factors and to assess the effect of early isolation of gram negative bacteria on recipients' mortality during the first 90 days after transplantation. During the study period 185 clinical isolates of gram negative bacteria were reported, for an incidence of 2.39 per 1000 recipient-days. Positive cultures for gram negative bacteria occurred early after transplantation (median time 26 days; incidence rate 4.33, 1.67 and 1.14 per 1,000 recipient-days in the first, second and third month after SOT, respectively). Forty-nine of these clinical isolates were due to carbapenem-resistant gram negative bacteria (26.5%; incidence 0.63 per 1000 recipient-days). Carbapenems resistance was particularly frequent among Klebsiella spp. isolates (49.1%). Recipients with longer hospital stay and those who received either heart or lung graft were at the highest risk of testing positive for any gram negative bacteria. Moreover recipients with longer hospital stay, lung recipients and those admitted to hospital for more than 48h before transplantation had the highest probability to have culture(s) positive for carbapenem-resistant gram negative bacteria. Forty-four organ recipients died (0.57 per 1000 recipient-days) during the study period. Recipients with at least one positive culture for carbapenem-resistant gram negative bacteria had a 10.23-fold higher mortality rate than those who did not. Conclusion The isolation of gram-negative bacteria is most frequent among recipient with hospital stays >48 hours prior to transplant and in those receiving either heart or lung transplants. Carbapenem-resistant gram negative isolates are associated with significant mortality.
