Staphylococcus aureus infections and factors associated with resistance to methicillin in a hospital emergency department 

JUAN GONZÁLEZ-CASTILLO, CATERINA CENCI, ESTHER RODRIGUEZ-ADRADA, FRANCISCO JAVIER CANDEL, FERNANDO DE LA TORRE-MISIEGO, CRISTINA FERNÁNDEZ, FRANCISCO JAVIER MARTÍN-SÁNCHEZ             

Objective. Assessment of the characteristics of patients with Staphylococcus aureus (SA) infections, and factors associated with resistance to methicillin in a hospital emergency department (ED) in Spain.
Materials and Methods. All adult patients admitted between January 2007 and December 2010 with a SA infection confirmed by a positive culture in a sample obtained in the hospital emergency department were selected for enrolment. Epidemiological, clinical, therapeutic and microbiological variables were retrospectively collected from the patients’ medical charts. The variable assessed within the primary outcome of the study was the isolation of methicillin resistant Staphylococcus aureus (MRSA). For the purpose of the analysis, the sample was divided in terms of the presence or not of the resistance to methicillin and a logistic regression analysis was performed to identify the factors associated with isolation and empirical antibiotic coverage of MRSA.
Results. A total of 207 patients with a confirmed SA infection were included in the study analysis, with a mean age of 64.7 (SD 20) years. MRSA was isolated in a total of 63 (30.4%) patients, and a linear incremental trend was observed over the course of the study (p=0,047). MRSA was empirically covered in the emergency department on an average rate of one in three patients. Independent factors associated with the isolation of MRSA were: age above 65 years [OR 2.97 (95% CI 1.24 to 7.1), P = 0.014], severe baseline functional dependence [OR 2.41 (95 % 1.02 to 5.69), P = 0.045], chronic obstructive pulmonary disease [OR 4.83 (95% CI 1.88 to 12.42), P = 0.001], history of antibiotic treatment within the previous 2 months [OR 4.94 (95% CI 2.27 to 10.76), P <0.001] and a confirmed urinary infection [OR 5.98 (95% CI 1.65 to 21.69) p = 0.007]. Independent factors associated with empiric coverage of MRSA in the ED were history of antibiotic treatment within the previous 2 months [OR 3.88 (95% CI 1.76 to 8.57), P <0.001] and the presence of a catheter device [OR 6.28 (95% CI 1.64 to 24.07), P = 0.007].
Conclusions. Resistance to methicillin appears to be increasingly frequent in patients infected with SA admitted in our emergency department and there appears to be a need for a more optimal empiric antibiotic treatment in these patients.

Rev Esp Quimioter 2013:26(4):337-345 [pdf]

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.

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

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.

 

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

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.

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

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.

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