Rev Esp Quimioter 2014:27(1):1-16

Clinical indications for therapeutic drug monitoring of antifungal agents. In the way for optimizing the treatment of fungal infection                                 
 

EMILIO CENDEJAS-BUENO, MANUEL CUENCA-ESTRELLA, ALICIA GÓMEZ-LÓPEZ               

Therapeutic drug monitoring as a tool in the management of infectious diseases has been introduced in therapy with anti-infective agents for years. Nowadays, it has taken importance in the management of fungal diseases due to the appearance of new antifungal drugs such as new-generation azoles. These azoles have pharmacokinetic characteristics that hinder a proper use to ensure efficacy and minimize toxicity. Monitoring of serum concentrations may help in the better use of these anti-infective agents, as well as in a better management of drug interactions, infectious disease and adverse effects. It has resulted in saving costs of treatment and in avoiding inadequate dosages. This review will attempt to clarify the role of the antifungal agents Therapeutic Drug Monitoring, highlighting the role of azole compounds.

Rev Esp Quimioter 2014:27(1):1-16 [pdf]

/por

Rev Esp Quimioter 2014:27(2):115-121

Review of 1.250 episodes of skin and soft tissue infections attended at 49 hospital emergency departments                                 
 

FERRAN LLOPIS, JUAN GONZÁLEZ-CASTILLO, AGUSTÍN JULIÁN-JIMÉNEZ, CARLES FERRÉ, JULIO JAVIER GAMAZO-RÍO, MIKEL MARTÍNEZ Y EL GRUPO DE TRABAJO INFURG-SEMES               

Objetive. To review the prevalence, clinical characteristics, approach and outcome of patients with skin and soft tissue infections (SSTI) evaluated at the Emergency Departments (ED) in Spain.
Methods. A descriptive multicenter cross-sectional analysis in 49 ED of patients with SSTI. Data were collected for age, gender, comorbid conditions, risk factors for multiresistant pathogens, STTI type, sepsis criteria, microbiology, antibiotic treatment, destination and ED mortality.
Results. We documented 1,250 episodes (11% of all infections and 1.6% of all patients seen in ED), mean age 52 years (56% men) and the comorbidities and risk factors for major adverse outcomes were diabetes (15%), heart disease (12%), previous antibiotic therapy (10%) and solid malignancy (5%). 81% of STTI were nonnecrotizing, 3.3% had septic syndrome, in 65% of patients was not practised any microbiological study, and 16% had risk factors for infection for antibiotic-resistant gram-positive bacteria, with adequate empirical antibiotic therapy of 2.5%. 72% of patients were discharged home and 2 died. When comparing STTI discharged home respect those that were admitted, these latter were older patients with more comorbidities and risk factors for multidrug resistance, sepsis and there were more practised cultures (p < 0.05).
Conclusions. The SSTI have a prevalence of 1.6%, representing 11% of visits to the ED for infection. 44% of patients have comorbidity and 16% have risk factors for infection for resistant gram-positive pathogens and they were not made an appropriate antibiotic coverage.

Rev Esp Quimioter 2014:27(2):115-121 [pdf]

/por

Rev Esp Quimioter 2014:27(1):17-21

Antifungal susceptibility of clinical isolates of Scopulariopsis species                                
 

VALLE ODERO, LIDIA GARCÍA-AGUDO, INMACULADA GUERRERO, PILAR AZNAR, PEDRO GARCÍA-MARTOS, MANUEL RODRÍGUEZ-IGLESIAS               

Introduction. Scopulariopsis is a common soil saprophyte. In the last years the infections caused by Scopulariopsis species have increased, included superficial and invasive mycoses. This fungi has been reported resistant in vitro to some antifungal agents, although there is little information about this. The aim of the study was to establish in vitro antifungal susceptibility of clinical isolates of Scopulariopsis species against to broad-spectrum antifungal agents.
Methods. A total of 28 Scopulariopsis strains (10 S. brevicaulis, 7 S. koningii, 3 S. acremonium, 3 S. candida, 3 S. flava, 1 S. brumptii and 1 S. fusca) were tested using Sensititre YeastOne and broth microdilution methods to determine the minimum inhibitory concentrations (MICs) to amphotericin B, fluconazole, itraconazole, posaconazole, voriconazole and 5-fluorocytosine, and minimun effective concentration (MECs) to anidulafungin, caspofungin and micafungin.
Results. Our data confirm the high in vitro resistance of Scopulariopsis to antifungal agents. Anidulafungin, caspofungin, micafungin (MICs ≥8 mg/L), 5-fluorocytosine (MICs ≥64 mg/L), and fluconazole (MICs ≥128 mg/L) were inactive in vitro in all species. MICs of amphotericin B (range 2 to ≥8 mg/L) and itraconazole (0.5 to ≥16 mg/L) were high. The best antifungal activity was observed for posaconazole and voriconazole (0.5 to ≥8 mg/L). With Sensititre YeastOne method MICs obtained slightly lower. Scopulariopsis candida, S. flava and S. fusca were the most resistant species, while S. acremonium and S. brevicaulis showed the lowest MICs.
Conclusions. MICs of all tested antifungal agents for Scopulariopsis were very high. Infections caused by Scopulariopsis species may not respond to antifungal treatment. Voriconazole is the drug of choice for treatment. We consider it appropriate to add amphotericin B in serious infections.

Rev Esp Quimioter 2014:27(1):17-21 [pdf]

/por

Rev Esp Quimioter 2014:27(2):122-126

Epidemiology of Clostridium difficile-associated disease (CDAD) in Salamanca                                 
 

MARÍA SILLER-RUIZ, NOELIA CALVO-GARCÍA, SARA HERNÁNDEZ-EGIDO, ANA MARÍA-BLÁZQUEZ, MÓNICA DE FRUTOS-SERNA, JOSÉ ELÍAS GARCÍA-SÁNCHEZ               

Introduction. Clostridium difficile infection is considered a major cause of nosocomial diarrhoea in developed countries and is increasingly becoming more important as an etiologic agent of community diarrhoea, also in patients without risk factors.
Method. Beginning in May 2011, the aim of our study is to know the characteristics of patients suffering from C. difficile Associated Disease in Salamanca University Hospital, collecting their data in a survey conducted for this purpose. A case was defined as a patient with compatible clinical and positive microbiological diagnosis.
Results. After 18 months of study, 41 cases had been documented representing an incidence of 1.15 cases per 10,000 patient-days. Patients were hospitalized (37) or health care associated (4), females (54%), age ≥65 years (56%) with prior antibiotic treatment (80%), most had diarrhea after the third day of admission, less than three weeks and without blood. Most were treated with metronidazole alone (78%), 19% with metronidazole and vancomycin, and the remaining percentage was resolved without treatment. Recurrences were about 20% and 7 (17%) died.
Conclusions. The characteristics of our patients with C. difficile – associated disease are the same as those reported by other authors. Local surveillance is important in order to study the endemic and epidemic C. difficile infection. According to published epidemiological changes, we sould be able to develop strategies from the Microbiology laboratories that will improve diagnosis of the disease.

Rev Esp Quimioter 2014:27(2):122-126 [pdf]

/por

Rev Esp Quimioter 2014:27(1):22-27

Microbiological study of infectious endophthalmitis with positive culture within a 13 year-period                                 
 

MARÍA ÁNGELES ASENCIO, MARÍA HUERTAS, RAFAEL CARRANZA, JOSÉ MARÍA TENÍAS, JAVIER CELIS, FERNANDO GONZÁLEZ-DEL VALLE               

Introduction. Our objectives are to describe the microbial spectrum and antimicrobial susceptibility of isolates from patients with culture-proven endophthalmitis.
Material and methods. Retrospective study of patients with microbiological diagnosis of endophthalmitis treated at the Ophthalmology Department of the General Hospital La Mancha Centro in the period 1996-2008. The identification of isolates was performed using the automated VITEK-2® and Api galleries (bioMérieux, Spain SA). The antimicrobial susceptibility was performed by the VITEK-2® system (bioMérieux, Spain SA), E-test strips (MIC Test Strip, Liofilchem, Italy) and Sensititre® YeastOne trading system (Trek Diagnostic Systems, Ohio, USA) for Candida species.
Results. Forty four (70%) of 63 cases of endophthalmitis were culture positive. Gram-positive bacteria were much more common than gram-negative bacteria in both postoperative endophthalmitis (POE) and post-traumatic endophthalmitis (PTE). Staphylococcus epidermidis was predominant in POE, while Bacillus sp. predominated in the PTE; furthermore, the 75% of total fungal isolates corresponded to postraumatic cases. The isolated strains showed 100% susceptibility to vancomycin, ceftazidime and amikacin, while resistance to ciprofloxacin was greater than 15%. The empirical antifungal therapy failed in 50% of cases. The visual prognosis was significantly less favorable in the PTE.
Conclusions. Based on the susceptibility of our isolates, vancomycin, ceftazidime and amikacin are good choices for empirical treatment of endophthalmitis, unlike ciprofloxacin. We recommend conducting antifungal prophylaxis after penetrating ocular trauma in a rural environment.

Rev Esp Quimioter 2014:27(1):22-27 [pdf]

/por

Rev Esp Quimioter 2014:27(2):134-139

Correction: Antimicrobial stewardship in patients recently transferred to a ward from the ICU                                 
 

ANTONIO RAMOS, LAURA BENÍTEZ-GUTIERREZ, ANGEL ASENSIO, BELÉN RUIZ-ANTORÁN, CARLOS FOLGUERA, ISABEL SANCHEZ-ROMERO, ELENA MUÑEZ               

This paper is a corrigendum to the previously published paper: “Antimicrobial stewardship in patients recently transferred to a ward from the ICU” [Rev Esp Quimioter. 2014 Mar;27(1):46-50.] This corrigendum was prepared in order to correct some erroneous comments included in the discussion section. First, it should be pointed out that there could have been several suitable options for treating many infections and that, therefore, the word “inadequate” was not the most appropriate in this situation. In addition, some comments about the interpretation of microbiological results made by ICU physicians have been removed from the first article because this variable was not included in the study. Finally, another change made to the discussion was to clarify the ICU physicians’ alleged low level of compliance with advice given by infectious disease specialists. This has been suggested in previous studies it cannot be substantiated when analyzing the results of the study.
Purpose. Inappropriate use of antibiotics is an important health problem that is related to increasing bacterial resistance. Despite its relevance, many health institutions assign very limited resources to improving prescribing practices. An antimicrobial stewardship programme (APS) centred on patients discharged from the ICU could efficiently undertake this task.
Methods. During this six month study the main activity was performing a programmed review of antimicrobial prescriptions in patients transferred to the ward from the ICU. In the case of amendable antimicrobial treatment, a recommendation was included in the medical record.
Results. A total of 437 antimicrobial prescriptions for 286 patients were revised during a six month period and a total of 271 prescriptions (62%) in 183 patients were considered to be amendable. In most of these cases, treatment could have been reduced taking into consideration each patient’s clinical improvement and their location in a hospital area with a lower risk of infection due to resistant bacteria. The most common advice was antimicrobial withdrawal (64%), antimicrobial change (20%) and switching to oral route (12%). Proposed recommendations were addressed in 212 cases (78%). There was no significant difference in adherence with respect to the type of recommendation (p=0.417). There was a 5% lower use of antibiotics during the year the study was conducted compared to the previous one.
Conclusions. ASPs centred on patients discharged from the ICU may be an efficient strategy to ameliorate antimicrobial use in hospitals.

Rev Esp Quimioter 2014:27(2):134-139 [pdf]

/por

Rev Esp Quimioter 2014:27(1):28-35

Antibiotic prescribing and changes in antimicrobial resistances in the health area of Segovia (Spain) during the period between 2007 and 2011                                
 

SONIA MIGUÉLEZ-FERREIRO, ELENA MORENO-SÁNCHEZ, MARÍA GUTIÉRREZ-DE ANTONIO, SUSANA HERNANDO-REAL               

Introduction. We analyzed the antibiotic prescribing and resistances of respiratory and urinary pathogens more common in the Health Area of Segovia in the period 2007-2011. The aim of the study was to investigate variability, time trends of antibiotic prescribing and correlation with changes in the antimicrobial resistance patterns.
Material and methods. Retrospective cross-sectional study. Antibiotic consumption was expressed in defined daily doses (DDD) per 1000 inhabitants per day (DHD). The antimicrobial resistance was expressed in percentages. Trend analysis was performed testing Spearman and Pearson correlation coefficients.
Results. The average antibiotic prescribing was 14.17 DHD, the coefficient and low ratio was 38.93% and 17.94. Penicillins was the most prescribed group (73%). Rural localization, lack of training MIR, distance to hospital and percentage of patients >65 years; showed significant association with increased antibiotic prescribing. Resistance of E. coli to cotrimoxazole and resistance of H. influenzae to amoxicillin decreased both by 8%. Resistance of S. pyogenes to erythromycin decreased by 5%. Resistances of S. pneumoniae to penicillin and E.coli to cephalosporins were both increased by 12%. Correlation between antibiotic prescription and resistances did not show singnificative results.
Conclusions. Prescribing of antibiotics decreased by 3.2% during the period. The use of broad-spectrum antibiotics was increased. Geographic wide variation in antibiotic prescribing was detected, also between physicians. There were not obtained conclusive data from the correlation between antibiotic prescribing and antimicrobial resistance.

Rev Esp Quimioter 2014:27(1):28-35 [pdf]

/por

Rev Esp Quimioter 2014:27(3):159-169

Pharmaceutical intervention in duration of antimicrobial treatment at hospital ambit                                 
 

MARÍA MORANTE, CARMEN MATOSES-CHIRIVELLA, FRANCISCO JOSÉ RODRÍGUEZ-LUCENA, JOSÉ MANUEL DEL MORAL, MONTSERRAT RUIZ-GARCÍA, ANDRÉS NAVARRO-RUIZ               

Objective. To estimate the acceptance of the pharmaceutical intervention in controlling duration of antimicrobial therapy
and to evaluate their impact on optimizing the treatment.
Methods. Prospective observational study for two years in a General University Hospital. For the patients record, we followed non critical adult patients with antibiotic treatment. When the duration of antimicrobial treatment not complied with established criteria for each antibiotic and pathology, there was a communication with the physician, at which is recommended to assess the need for continue treatment. The acceptance of pharmaceutical intervention was collected and afterwards we analyzed the impact of this work by antimicrobial consumption and incidence of Clostridium difficile.
Results. In 122 patients the pharmacist made a pharmaceutical intervention due to prolonged antibiotic treatment. The most prevalent antibiotics were β-lactams, specifically meropenem. The intravenous administration was more frequent. In 77 cases it was decided to recommend the suspension of treatment, we conducted an orally prospective intervention at 70.15 % and the rest of interventions were written. Acceptance was 65.95 % and 65.00%, respectively. During the study period, the DDD of the antimicrobials decreased by 8.89% and expenditure on antimicrobials one 40.12%. The incidence of C. difficile was stable.
Conclusions. In a hospital, a pharmaceutical counselling program on the duration of antimicrobial therapy is well accepted by the prescriber physician, but it must be improved. The route of information does not affect the degree of acceptance. These actions could involve a reduction of antimicrobial consumption.

Rev Esp Quimioter 2014:27(3):159-169 [pdf]

/por

Rev Esp Quimioter 2014:27(1):36-42

Use of Digital Health Records and “WebMovil” corporate service in the communication management of critical results of Microbiology, in the context of a primary health care area                                
 

ANTONIO FRANCISCO GUZMÁN-GONZÁLEZ, FEDERICO NAVAJAS-LUQUE, JOSÉ DE LA TORRE-FERNÁNDEZ               

Introduction. The objective was to describe and evaluate a new communication protocol of reporting critical results applied to Microbiology in a health area of Andalusia.
Material and methods. The size and type of the critical values of Microbiology are analyzed for primary care patients. A new computerized reporting system was analyzed, in real time, through Diraya Digital Health Records, which integrates the analytical test module (MPA). The protocol is complemented, in collaboration with the Information Technology (IT), with the Junta de Andalucía short message service (SMS) “WebMovil”.
Results. The total number of notices of critical results by the new protocol in 2012 was 817. The number of critical values for primary care was 570, of which 90 were for Microbiology. The most frequent notice was by isolation in the stool culture (n = 51; 56.67%). The prevalence of the critical values of Microbiology in primary care was 0.45/100. The average time of notifications was 13 minutes. The success rate of notifications was 97.7% and 0% obtained in the number of withdrawals. In 99.93% of cases the contact with the patient was stated and in 98.55% the medical intervention was also confirmed.
Conclusions. Communication by a computerized system linked to the SMS technology showed a reduction in the time of notification, and produced additional benefits, such as eliminating the risk of error when there is no repetition of information from the recipient received by the laboratory. Furthermore, the use of SMS messages ensures that doctors on duty always receive information immediately.

Rev Esp Quimioter 2014:27(1):36-42 [pdf]

/por

Rev Esp Quimioter 2014:27(3):170-179

Reduction in diabetic amputations over 15 years in a defined Spain population. Benefits of a critical pathway approach and multidisciplinary team work                                 
 

DIEGO DE ALCALÁ MARTÍNEZ-GÓMEZ, M. ANGELES MORENO-CARRILLO, ALVARO CAMPILLO-SOTO, ANDRÉS CARRILLO-GARCÍA, JOSÉ LUÍS AGUAYO-ALBASINI               

Objective. To assess changes in diabetic lower-extremity amputations (LEA) rates in a defined population over a 15-year period, following a multidisciplinary approach including a critical pathway in an inpatient setting with standardized preoperative and postoperative care, as well as in an outpatient setting through the establishment of a diabetic foot clinic.
Methods. This is a study of the incidence and types of LEAs performed in patients with diabetic foot disease complicated admitted to Morales Meseguer Hospital (Murcia, Spain), a large district general hospital, before (1998-2000) and after (2001-2012) of the introduction of better organized diabetes foot care. Hospital and clinic characteristics to the success of the programme are described. All cases of LEA in diabetic patients (1998-2012) within the area were identified by ICD-9-Clinical modification (CM) diagnostic codes. A chi square test was used to compare the frequency and level of amputations.
Results. Over all inpatients with diabetes admitted with foot infections and gangrene, there was a significant decrease in the proportion of total major amputations (47%) and elective major amputations (66%) (p<0.001). The incidence of total major amputations rates per 100.000 of the general population fell with statistical significance (p=0.009). The biggest improvement in LEA incidence was seen in the reduction of major elective amputation with fell 60%, from 7.6 to 3.1 per 100,000 (p<0.001).
Conclusions. Significant reductions in total and major amputations rates occurred over the 15-year period following improvements in foot care services included multidisciplinary teamwork (critical pathway and diabetic foot clinic).

Rev Esp Quimioter 2014:27(3):170-179 [pdf]

/por