Le infezioni in medicina : rivista periodica di eziologia, epidemiologia, diagnostica, clinica e terapia delle patologie infettive
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The prognosis of HIV-infected patients has dramatically improved since the advent of HAART. The immune recovery associated with HAART may result in immuno-pathological reactions and clinical deterioration when HAART is initiated in patients with tuberculosis (TB). This phenomenon is defined as immune reconstitution inflammatory syndrome (IRIS). In this review, we summarise the epidemiology, clinical presentations and management of TB-associated IRIS.
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Abdominal sepsis carries a high morbidity and mortality. Intra-abdominal infectious complications are one of the most common infectious etiologies seen in critically ill patients. Approximately 30% of patients admitted to an ICU with intra-abdominal infection succumb to their illness, and when peritonitis arises as a complication of a previous surgical procedure, or recurs during ICU admission, mortality rates exceed 50%. ⋯ For diagnosis of intra-abdominal conditions using CT scanning it is optimal if patients receive both oral and intravenous contrast. An exception to the use of CT scanning is evaluation of suspected biliary pathology, which is best imaged by ultrasound. It will identify cholecystitis with or without calculus and may show changes in the gallbladder or common bile duct associated with biliary obstruction.
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Review Comparative Study
[Guidelines for treatment of pneumonia in intensive care units].
Patients affected by pneumonia can be admitted in Intensive Care Units (ICUs) independently by the setting where the infection has been acquired (community, hospital, long-term care facilities); even more frequently pneumonia can develop in patients already hospitalized in ICU especially in those requiring mechanical ventilation for different reasons. Within the severe community acquired pneumonia requiring admission in ICU, the most frequently responsible micro-organisms are mainly represented by Streptococcus pneumoniae, but also by Legionella and Haemophilus. Pseudomonas aeruginona, anyway, cannot be excluded. ⋯ Late onset VAP and HAP in patients with risk factors for multi-resistant, by contrast, should be treated with a combination therapy: in case of defined or suspected P. aeruginosa, Klebsiella pneumoniae (ESbL+), Acinetobacter sp etiology, it is required the use of an anti-pseudomonas cephalosporin or an anti-pseudomonas carbapenem or b-lactam + beta-lactamase inhibitor associated with an anti-pseudomonas fluoroquinolone or an aminoglicoside. The possible presence of MRSA or Legionella pneumophila suggests the use of anti-Gram positive antibiotics such as glycopeptides or linezolid. These quidelines confirm the role of ciprofloxacin combined with beta-lactams whenever P. aeruginosa, Klebsiella pneumoniae (ESbL+), Acinetobacter sp. etiology is suspected.
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The life expectancy of HIV-infected patients treated with highly active antiretroviral therapy (HAART) has increased and now approaches that of the general population, while also the definition of AIDS has lost most of its epidemiological and clinical significance, due to the immune recovery obtained by large-scale administration of potent antiretroviral combinations. The prolonged survival of subjects with HIV infection, and the late recognition of patients with occult disease, will contribute to a progressive increase in disease incidence in patients aged 50-60 years or more in the near future. Unfortunately, the large majority of therapeutic trials addressed to assess and compare novel antiretroviral molecules and associations, as well as studies regarding antimicrobial chemotherapy of prophylaxis of AIDS-related opportunistic infections, have just advanced age and/or underlying chronic disorders (i.e. liver or kidney failure) among main exclusion criteria, or do not allow the extrapolation of data regarding older subjects, compared with younger ones. ⋯ However, immune reconstitution is often slower and blunted according to age progression, although some well-designed studies have shown that the thymic function (which controls most quantitative and functional immune recovery) can be preserved in adults and even in advanced age. When facing older subjects, the Infectious Disease specialist has to pay careful attention to any chronic end-organ disorders, all possible pharmacological interactions, and overwhelming toxicity due to underlying drug therapies: all these issues may significantly interfere with HAART efficacy, patients' adherence to prescribed treatments, and frequency and severity of untoward events. Guidelines for antiretroviral therapy and treatment and prophylaxis of AIDS-associated illnesses should be appropriately updated, given the novel features due to the emerging increase in the mean age of the HIV-infected patient population.
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Surgical site infections (SSIs) are a notable cause of hospital morbidity and mortality. Antibiotic prophylaxis has demonstrated a significant reduction in infection rate in clean-contaminated surgery and in clean surgery to a limited extent. To make antibiotic prophylaxis effective it is necessary to choose the right antibiotic, to administer it preoperatively and maintain sufficient serum and tissue levels through the operation. Open issues remain: antibiotic prophylaxis duration in prosthetic surgery, its use in hernia repair, breast surgery and mini-invasive surgery.