Epidemiology, risk factors, and clinical effect of infections by multiresistant bacteria in cirrhosis are poorly known. This work was a prospective evaluation in two series of cirrhotic patients admitted with infection or developing infection during hospitalization. The first series was studied between 2005 and 2007 (507 bacterial infections in 223 patients) and the second between 2010 and 2011 (162 bacterial infections in 110 patients). In the first series, 32% of infections were community acquired (CA), 32% healthcare associated (HCA), and 36% nosocomial. Multiresistant bacteria (92 infections; 18%) were isolated in 4%, 14%, and 35% of these infections, respectively ( P < 0.001). Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL- E ; n = 43) was the main multiresistant organism identified, followed by Pseudomonas aeruginosa (n = 17), methicillin-resistant Staphylococcus aureus (n = 14), and Enterococcus faecium (n = 14). The efficacy of currently recommended empirical antibiotic therapy was very low in nosocomial infections (40%), compared to HCA and CA episodes (73% and 83%, respectively; P < 0.0001), particularly in spontaneous bacterial peritonitis, urinary tract infection, and pneumonia (26%, 29%, and 44%, respectively). Septic shock (26% versus 10%; P < 0.0001) and mortality rate (25% versus 12%; P = 0.001) were significantly higher in infections caused by multiresistant strains. Nosocomial origin of infection (hazard ratio [HR], 4.43), long-term norfloxacin prophylaxis (HR, 2.69), recent infection by multiresistant bacteria (HR, 2.45), and recent use of β-lactams (HR, 2.39) were independently associated with the development of multiresistant infections. Results in the second series were similar to those observed in the first series. Conclusions : Multiresistant bacteria, especially ESBL-producing Enterobacteriaceae , are frequently isolated in nosocomial and, to a lesser extent, HCA infections in cirrhosis, rendering third-generation cephalosporins clinically ineffective. New antibiotic strategies tailored according to the local epidemiological patterns are needed for the empirical treatment of nosocomial infections in cirrhosis. (Hepatology 2012)

The current COVID-19 pandemic underlines the importance of a mindful utilization of financial and human resources. Preserving resources and manpower is paramount in healthcare. It is important to ensure the ability of surgeons and specialized professionals to function through the pandemic. A conscious effort should be made to minimize infection in this sector. A high mortality rate within this group would be detrimental.This manuscript is the result of a collaboration between the major Italian surgical and anesthesiologic societies: ACOI, SIC, SICUT, SICO, SICG, SIFIPAC, SICE, and SIAARTI. We aim to describe recommended clinical pathways for COVID-19-positive patients requiring acute non-deferrable surgical care. All hospitals should organize dedicated protocols and workforce training as part of the effort to face the current pandemic.

Objective: To determine the usefulness of ultrasound to evaluate central venous catheter misplacements and detection of pneumothorax, thus obviating postprocedural radiograph. After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip and detect postprocedural complications. Design: Prospective observational study. Setting: Adult intensive care unit. Patients: 111 consecutive patients undergoing central venous catheter positioning, using a landmark technique and contrast-enhanced ultrasonography. Measurements and Main Results: A postprocedural chest radiograph was obtained for all patients and was considered as a reference technique. At the end of the procedure, a B-mode ultrasonography was first performed to assess catheter position and detect pneumothorax. Right atrium positioning was detected in 19 patients by ultrasonography, and an additional six by contrast enhanced ultrasonography. Combining ultrasonography and contrast enhanced ultrasonography yielded a 96% sensitivity and 93% specificity in detecting catheter misplacement. Concordance was 95% and κ value was 0.88 (p < .001). Pneumothorax was detected in four patients by ultrasonography and in two by chest radiograph (concordance = 98%). The mean time required to perform ultrasonography plus contrast enhanced ultrasonography was 10 ± 5 mins vs. 83 ± 79 mins for chest radiograph (p < .05). Conclusions: The close concordance between ultrasonography plus contrast enhanced ultrasonography and chest radiograph justifies the use of sonography as a standard technique to ensure the correct positioning of the catheter tip and to detect pneumothorax after central venous catheter cannulation to optimize use of hospital resources and minimize time consumption and radiation. Chest radiograph will be necessary when sonographic examination is impossible to perform by technical limitations.