Rev Esp Quimioter 2013:26(1):21-29

Morbidity and mortality associated with primary and catheter-related bloodstream infections in critically ill patients                                  
 

P. M. OLAECHEA, M. PALOMAR,  F. ÁLVAREZ-LERMA,  J. J. OTAL,  J. INSAUSTI,  M. J. LÓPEZ-PUEYO Y EL GRUPO ENVIN-HELICS                

Purpose. To analyze the impact of primary and catheter related bloodstream infections (PBSI/CRBSI) on morbidity and mortality.
Methods. A matched case-control study (1:4) was carried out on a Spanish epidemiological database of critically ill patients (ENVIN-HELICS). To determine the risk of death in patients with PBSI/CRBSI a matched Cox proportional hazard regression analysis was performed.
Results. Out of the 74,585 registered patients, those with at least one episode of monomicrobial PBSI/CRBSI were selected and paired with patients without PBSI/CRBSI for demographic and diagnostic criteria and seriousness of their condition on admission to the Intensive Care Unit (ICU). For mortality analysis, 1,879 patients with PBSI/CRBSI were paired with 7,516 controls. The crude death rate in the ICU was 28.1% among the cases and 18.7% among the controls. Attributable mortality 9.4% (HR:1.20; 95% confidence interval: 1.07–1.34; p<0.001). Risk of death varied according to the source of infection, aetiology, moment of onset of bloodstream infection and severity on admission to the ICU. The median stay in the ICU of patients who survived PBSI/CRBSI was 13 days longer than the controls, also varying according to aetiology, moment of onset of bloodstream infection and severity on admission.
Conclusions. Acquisition of PBSI/CRBSI in critically ill patients significantly increases mortality and length of ICU stay, which justifies prevention efforts.de prevención.

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Rev Esp Quimioter 2013:26(2):119-127

Bacteraemia at a second level hospital: epidemiological study, analysis of pronostic factors associated to mortality and economic cost estimation                                
 

JOSÉ JOAQUÍN HERNÁNDEZ-ROCA, ELISA GARCÍA-VÁZQUEZ, ALICIA HERNÁNDEZ, MANUEL CANTERAS, JOSÉ ANTONIO HERRERO, EVA CASCALES, ENRIQUE MENÉ-FENOR, JOAQUÍN GÓMEZ-GÓMEZ
             

Introduction. Bacteraemia (B) accounts for a considerable proportion (0.36%) of all hospital admissions due to infections diseases and it is associated to increased hospital costs. The aim of this study is to describe a cohort of patients with bacteraemia  at a second level hospital, to analyze factors associated to mortality and its economical impact during hospital admission.
Patients and Methods. Observational study of a cohort of adult patients with bacteraemia admitted at a second level hospital during 2010. Data collection from clinical records has been done according to a standard protocol: epidemiological and clinical variables and factors associated to mortality were analysed. Total economical cost per patient was estimated.
Results. 148 patients were included: 80 community B (55.4%), 23 health care associated B (15.5%) and 45 nosocomial B (28.5%). The incidence was 9 cases 10.000 persons/year. Mean age was 69 years and the global mortality was 24%. In bivariate analysis smoking, diabetes mellitus, McCabe Jackson score type I-II, Pitt Index ≥ 3, APACHE ≥ 20, Glasgow ≤9, shock, respiratory distress, invasive procedures, nosocomial bacteraemia and inadequate empiric or definitive antibiotic treatment were associated to mortality (p<0.05). Factors associated to mortality in multivariate analysis included McCabe Jackson score type I-II (OR 4.95; 95% CI 1.095-22.38), haemodialysis during acute stage (OR 7.8; 95% CI 2.214-27.773) and inadequate empiric antibiotic treatment (OR 7.68; 95% CI 19.82-29.77). Admission economic cost per patient was 9,459€ for community acquired bacteriemia, 5,656€ for health care associated bacteraemia and 41,680€ for nosocomial bacteraemia.
Conclusions. Comorbidity, inadequate empiric antibiotic treatment and haemodialysis during acute phase are statistically significantly in our cohort of patients with bacteraemia.

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Rev Esp Quimioter 2013:26(4):346-352

Influence of ethnicity on the pharmacokinetics of amikacin 

MELISA BARRANTES-GONZÁLEZ, SANTIAGO GRAU, DAVID CONDE-ESTÉVEZ, ESTHER SALAS, MÓNICA MARÍN-CASINO             

Objective. Despite the increasing ethnic diversity, there are few studies of its influence on the pharmacokinetics of amikacin. The objective of this study was to compare the pharmacokinetics of amikacin in different populations: Asian, Hispanic, North Africans and Caucasian.
Methods. A retrospective observational study was performed in a tertiary teaching hospital during eight years. It was included all patients with intravenous amikacin treatment in extended interval dosing regimen with therapeutic drug monitoring of amikacin. Pharmacokinetic parameters were analysed. A bivariate and multiple linear regression statistical analysis were carried out.
Results. 164 patients were included: 7 asians, 135 Caucasians, 11 Hispanics and 11 from North Africa. It was shown a lower plasma concentrations of amikacin in North Africa population due to its greater clearance.
Conclusions. Amikacin plasma concentrations monitoring is advisable in patients from North Africa in order to avoid subtherapeutic concentrations.

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Rev Esp Quimioter 2013:26(1):30-33

Pyelonephritis in pregnancy. How adequate is empirical treatment?                                  
 

A. ARTERO, J. ALBEROLA, J.M. EIROS,  J.M. NOGUEIRA, A. CANO                 

Objective. To ascertain the adequacy of empirical antimicrobial treatment in pregnant women with acute pyelonephritis.
Material and methods. We have conducted a retrospective observational study of women admitted to the hospital with acute pyelonephritis between May 2004 and April 2011.
Patients were included if the results of urine cultures and susceptibility testing to antibiotics were available. Epidemiological, clinical, therapeutical and outcome variables were collected from chart review. We considered inappropriate empirical antimicrobial treatment (IEAT) as the occurrence of microorganism that were not effectively treated at the time when the causative microorganism and its antibiotic susceptibility were known.
Results. Fifty women with appropriate microbiological data from a total of 93 cases of acute pyelonephritis were included in the study. The women’s mean age was 26.4 years, and 58% were nulliparous. Pyelonephritis was developed in the 2nd and 3rd trimester in 88% of cases. Previous urinary tract infections were recorded in 34%. Escherichia coli was the most frequent microorganism (70%). The proportion of patients who received IEAT was 10%. Amoxicillin-clavulanate and cepahlosporines were the most predominant antibiotics used, with a proportion of IEAT of 10.3% and 5.9%, respectively.
Conclusions. Pregnant women with pyelonephritis received IEAT in a small but significant number of cases. Amoxicillin-clavulante and cephalosporines were adequate in most cases. More studies are needed to define the clinical impact of IEAT on prognosis.

 

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Rev Esp Quimioter 2013:26(2):128-130

A rare case of Meleney’s Ulcer after partial chemical matricectomy                                
 

MARTA ELENA LOSA-IGLESIAS, RICARDO BECERRO-DE-BENGOA-VALLEJO
             

Background. Meleney’s ulcer is a rare, but potentially deadly infection that often occurs in post-surgical sites. This type of ulcer has not previously been reported in the toenail after phenol matricectomy.
Patient Case. A female patient underwent partial phenolization of the medial nail matrix of the hallux, but after 2 months had a recurrent spicula that caused Meleney’s ulcers.
Results. The ulcers remained after treatment with antibiotics, and further surgery was required to fully clear the infection.
Conclusion. This case and review of Meleney’s ulcer highlights the deceptively benign initial presentation of necrotizing fasciitis at the hallux after partial chemical matricectomy surgery using a phenol-based approach.

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Rev Esp Quimioter 2013:26(4):353-359

Prosthetic joint infections due to methicillin-resistant and methicillin-susceptible staphylococci treated with open debridement and retention of the prosthesis 

EDUARD TORNERO, LAURA MORATA, JUAN C MARTÍNEZ-PASTOR,  GUILLEM BORI, JOSEP MENSA, ALEX SORIANO             

Objectives. To compare the specific characteristics, the outcome and the predictors of failure of prosthetic joint infections (PJI) due to methicillin-resistant (MRS) and methicillin-susceptible staphylococci (MSS) treated with open debridement and retention of the implant.
Material and methods. PJI due to MRS or MRS prospectively registered in a database from 1999 to 2009 were retrospectively reviewed.
Results. During the study period, 96 patients met the inclusion criteria of the study. The mean follow-up period was 3.9 years and at least 2 years in all patients. The failure rate was 25%. The only variable significantly associated with failure in the global cohort was polymicrobial infection (59.3% vs. 40.7%, p=0.036). Thirty-four (35.4%) patients had an infection due to MRS and 62 (63.6%) due to MSS. Among MSS infections, 95.2% corresponded to primary arthroplasties while 29.4% of PJI due to MRS were after revision arthroplasties (p=0.001). CRP was significantly higher in PJI due to MSS (5.2 mg/dl vs 9.1 mg/dL, p=0.02).The failure rate (20% vs 27%, p=0.62) was very similar in MSS and MRS groups.
Conclusion. PJI due to MRS were mainly coagulase-negative staphylococci, more frequent after revision arthroplasties, had a lower inflammatory response, and had a similar failure rate than MSS infections.

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Rev Esp Quimioter 2013:26(1):34-38

Invasion of solid culture media: a widespread phenotypic feature of clinical bacterial isolates                                  
 

F. GÓMEZ-AGUADO, M. T. CORCUERA, C. GARCÍA-REY,  M. L. GÓMEZ-LUS, C. RAMOS, M. J. ALONSO, J. PRIETO                  

Objectives. The in-depth growth in solid culture media is a common feature in filamentous fungi and yeasts. However, there are very few bacterial species in which this phenomenon has been documented. The aim of this work was to assess the agar invasiveness of a wide range of Gram-positive and Gram-negative bacterial species of clinical interest.
Material and methods. Three different clinical isolates for each of eleven bacterial species were plated onto Columbia blood agar and let grow up to 15 days. Isolated colonies were processed by histological methods, embedded in epoxy resin, and then, semithin sections were stained with toluidine blue and visualized by light microscopy.
Results. Growth within the agar was observed in at least one strain in 9 of the 11 studied species. Invasions of Gramnegative rods were small, not plentiful, and round or triangleshaped. In Gram-positive cocci, invasions were of big size, abundant and of variable shape (lentiform, globular, irregular, arrowhead) depending on the species.
Conclusions: We propose that the growth within the agar can indicate a survival strategy common to many bacterial species, and so far, not previously reported. This strategy could be either a nutrient gradient tropism or the spread and colonization of new ecological niches, with potential implications in pathogeny.

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Rev Esp Quimioter 2013:26(2):131-150

EPICO PROJECT. Development of educational recommendations using the DELPHI technique on invasive candidiasis in non- neutropenic critically ill adult patients                                
 

THE EPICO PROJECT GROUP
             

Introduction. Although there has been an improved management of Invasive Candidiasis in the last decade, controversial issues still remain, especially in the diagnostic and therapeutic approaches.
Objectives. We sought to identify the core clinical knowledge and to achieve high level agreement recommendations required to care for critically ill adult patients with Invasive Candidiasis.
Methods. Prospective Spanish survey reaching consensus by the Delphi technique, anonymously conducted by electronic e-mail in a first term to 25 national multidisciplinary experts in invasive fungal infections from five national scientific societies, including Intensivists, Anesthesiologists, Microbiologists, Pharmacologists and Infectious Disease Specialists, responding to 47 questions prepared by a coordination group after a strict review of the literature in the last five years. The educational objectives spanned five categories, including epidemiology, diagnostic tools, prediction rules, and treatment and de-escalation approaches. The level of agreement achieved among the panel experts in each item should exceed 75% to be selected. In a second term, after extracting recommendations from the selected items, a face to face meeting was performed where more than 80 specialists in a second round were invited to validate the preselected recommendations.
Measurements and Main Results. In the first term, 20 recommendations were preselected (Epidemiology 4, Scores 3, Diagnostic tools 4, Treatment 6 and De-escalation approaches 3). After the second round, the following 12 were validated: Epidemiology: Think about Candidiasis in your ICU and do not forget that non-albicans species also exist. Diagnostic tools: Blood cultures should be performed under suspicion every 2-3 days and, if positive, every 3 days until obtaining the first negative result. Obtain sterile fluid and tissue, if possible (direct examination of the sample is important). Use nonculture based methods of microbiological tools, whenever possible. Determination of antifungal susceptibility is mandatory. Scores: As screening tool, use the Candida Score and determine multicolonization in high risk patients. Treatment: Start early. Choose Echinocandins. Withdraw the catheter. Fundoscopy is needed. De-escalation: Only applied when knowing susceptibility determinations and after 3 days of clinical stability. The higher rate of agreement was achieved in the optimization of microbiological tools and the withdrawal of the catheter, whereas the lower rate corresponded to de-escalation therapy and the use of scores.
Conclusions. The management of invasive candidiasis in ICU patients requires the application of a broad range of knowledge and skills that our summarized in our recommendations. These recommendations may help to identify the potential patients, standardize their global management and improve their outcomes, based on the DELPHI methodology.

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Rev Esp Quimioter 2013:26(4):360-368

Effectiveness of liposomal amphotericin B in patients admitted to the ICU on renal replacement therapy 

FRANCISCO ÁLVAREZ-LERMA, MONTSERRAT RODRIGUEZ, MARI CRUZ SORIANO, MERCEDES CATALÁN, ANA MARÍA LLORENTE, NIEVES VIDART, MARÍA GARITACELAYA, ENRIQUE MARAVI, ELISABETH FERNÁNDEZ REY, FRANCISCO ALVARADO, MARTA LÓPEZ-SÁNCHEZ, BERNABÉ ALVAREZ-SÁNCHEZ, DAVID GRANADO, ELISABETH QUINTANA AND THE STUDY GROUP OF LIPOSOMAL AMPHOTERICIN B IN THE ICU             

Introduction. This study was designed to compare the effectiveness of liposomal amphotericin B (L-AmB) in ICU patients with and without renal replacement therapy (RRT).
Methods. Observational, retrospective, comparative and multicenter study conducted in critically ill patients treated with L-AmB for 3 or more days, divided into two cohorts depending on the use of RRT before or within the first 48 hours after starting L-AmB. Clinical and microbiological response at the end of treatment was evaluated.
Results. A total of 158 patients met the inclusion criteria, 36 (22.8%) of which required RRT during the ICU stay. Patients with RRT as compared with those without RRT showed a higher APACHE II score on admission (21.4 vs 18.4, P = 0.041), greater systemic response against infection (P = 0.047) and higher need of supportive techniques (P = 0.002). In both groups, main reasons for the use of L-AmB were broad spectrum and hemodynamic instability. A higher daily dose of L-AmB was used in the RRT group (4.30 vs 3.84 mg/kg, P = 0.030) without differences in the total cumulative dose or treatment duration. There were no differences in the clinical response (61.1% vs 56.6%, P = 0.953) or microbiological eradication rate (74.1% vs 64.6%, P = 0.382). In patients with proven invasive fungal infection, satisfactory clinical response was obtained in 74.1% and microbiological eradication 85.7%.
Conclusions. Although the study sample is small, this study shows that L-AmB is effective in critically ill patients admitted to the ICU requiring RRT.

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Rev Esp Quimioter 2013:26(1):39-42

Relevance of the detection of Streptococcus pneumoniae antigen in human urine in the diagnosis of lower respiratory tract infections                                  
 

A. SORLÓZANO, S. CEDEÑO, J. GUTIÉRREZ-FERNÁNDEZ, P. POLO, J. M. NAVARRO                   

Background and objective. Techniques membrane antigen immunochromatographic detecting in urine the pneumococcal polysaccharide C, have developed significantly, increasing requests for antigenuria to clinical microbiology laboratories. We evaluated the impact of the application of this test in the diagnosis of infections of lower respiratory tract.
Patients and method. Six hundred and sixteen determinations were performed by antigenuria BinaxNOW® S. pneumoniae in as many patients over 14 years admitted to the Hospital Universitario Virgen de las Nieves (Granada) between November 2010 and March 2011.
Results. In 91.1% of patients who were determined antigenuria the presence of respiratory symptoms justified the request. Only 8.4% of 616 antigenurias performed were positive. S. pneumoniae was isolated from the respiratory sample culture in 8 of these 52 patients. In 29.8% of patients the diagnosis of lower respiratory tract infection was based on clinical, radiological and/or analytical, as antigenurias were negative and did not involve any other additional microbiological test.
Conclusions. We believe that this technique should be used in a complementary manner, and never to the detriment of other microbiological tests, especially in hospitalized patients.

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