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Rev Esp Quimioter 2018; 31(3):247-256

Results of the implementation of an Antimicrobial Stewardship Program in the “Gerencia de Atención Integrada” of Alcazar de San Juan (Castilla La Mancha)

MARÍA ÁNGELES ASENCIO EGEA, ÓSCAR HERRÁEZ CARRERA, MARÍA HUERTAS VAQUERO, HUGO DANIEL PATIÑO ORTEGA, MARÍA FRANCO HUERTA, PATRICIA ALCÁZAR CARMONA, MARÍA CARMEN CONDE GARCÍA, CRISTINA MUÑOZ-CUEVAS, CARMEN ROMÁN ORTIZ, JORGE GAITÁN PITERA, RAFAEL CARRANZA GONZÁLEZ, JOSÉ RAMÓN BARBERÁ

Introduction. Our aim was to evaluate the efficiency of an ASP after its implementation in 2016 in a Spanish hospital quality system.
Material and methods. Efficiency of the ASP was measured by process and outcome indicators at the level of the patient’s quality of life, antimicrobial consumption and percentage of resistance to them during the 2016-2017 period. In 2017, the failures mode and effects analysis (FMEA) methodology was applied. An annual satisfaction survey was conducted.
Results. The clinical indicators were within the threshold of acceptability, as well as the empirical prescription of antimicrobials, the consumption of antibiotics (reduction of 77 DDD in the first semester of 2016 to 26 in the second semester of 2017) and the renal (gentamicin) and neurological (carbapenems) toxicity. The FMEA identified as a main risk the lack of adequacy of the empirical treatment once the antibiogram was obtained; thus, a corrective action was taken in 2017. Regarding the microbiological indicators, the incidence of multi-drug resistant and carbapenemase-producing enterobacteria, and that of methicillin-resistant Staphylococcus aureus, were reduced. Eighty-three percent of the counselling activities carried out were accepted. The surveys revealed a good acceptance and spread of the program, the need for protocols and training in the use of antibiotics.
Conclusions. The implementation of the ASP in the quality system was efficient. The consumption of antibiotics and the adverse effects derived from their use were reduced, improving the quality of life of patients, and reducing health costs.

Rev Esp Quimioter 2018; 31(3):247-256 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(3):227-246

Monoclonal spread of multi-drug resistant CTX-M-15-producing Klebsiella pneumoniae. Impact of measures to control the outbreak

MARÍA ÁNGELES ASENCIO EGEA, MARÍA HUERTAS VAQUERO, CRISTINA MUÑOZ-CUEVAS, JORGE GAITÁN PITERA, ÓSCAR HERRÁEZ CARRERA, PATRICIA ALCÁZAR CARMONA, HUGO DANIEL PATIÑO ORTEGA, MARÍA FRANCO HUERTA, CARMEN ROMÁN ORTIZ, MARÍA CARMEN CONDE GARCÍA, RAFAEL CARRANZA GONZÁLEZ, JOSÉ RAMÓN BARBERÁ, VERÓNICA BAUTISTA SÁNCHEZ

Objective. To describe an outbreak of multi-drug resistant extended-spectrum β-lactamases-producing Klebsiella pneumoniae (MDR-ESBL-KPN) and the impact of measures for its control.
Material and methods. We reviewed the patients´ clinical records with MDR-ESBL-KPN isolation during 2013-2016 with resistance to fluoroquinolones, aminoglycosides, fosfomycin, and nitrofurantoin; susceptible to imipenem, meropenem, colistin, and tigecycline and variable to ertapenem and cotrimoxazole (Vitek-2). The genetic relationship between 35 isolates was established by PFGE and MLST. Control measures were put in place in January 2016.
Results. We detected 269 patients colonized and/or infected by KPN-ESBL-MDR with a common resistance phenotype; the strains studied carried the blaCTX-M-15 gene and formed a single cluster belonging to ST11. The outbreak was detected at the end of 2015, although it began in 2013 in an elderly center. The acquisition source of the strains was: 6% community-acquired, 37% hospital-acquired (76% in internal medicine) and 57% related to long health care facilities (78% of hospitalizations in the last year). Ninety-four percent of patients had at least one underlying disease, 90% received antibiotics previously and 49% had some invasive devices. After the introduction of control measures, the incidence of cases in the quarter was reduced from 29 to 15.
Conclusions. We detected a monoclonal outbreak of MDR-CTX-M-15-KPN in 2015, with predominance of health-care associated cases. The success in the rapid spread of the outbreak was due to the delay in its detection and to the fact that most of the patients had previously received antibiotics. The control measures reduced the number of isolates by 50%.

Rev Esp Quimioter 2018; 31(3):227-246 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(3):226-236

Direct-acting antiviral agents in patients with hepatitis C genotype 1-4 infections in a tertiary hospital

JUAN CARLOS DEL RIO-VALENCIA, ROCÍO ASENSI-DIEZ, LORENZO VILLALOBOS-TORRES, ISABEL MUÑOZ CASTILLO

Introduction. Hepatitis C virus (HCV) infection is a major cause of chronic liver disease. Six different genotypes (GT) of HCV (genotypes 1-6) have been identified. The genotype is clinically relevant since the majority of current direct antiviral agents (DAA´s) do not have pangenotypic efficacy. The purpose of this study was to describe the clinical characteristics of real world patients and evaluate the effectiveness of different treatment regimens.
Material and methods. Retrospective and observational study carried out in a third level hospital. Study period: January 2015-January 2016. Inclusion criteria: HCV patients of any genotype treated with either DAAs ± rivabirin (RBV) or DAAs + RBV + pegilated interferon (Peg-IFN) regimens for 12 weeks. Exclusion criteria: patients without adequate clinical or analytical information available for further analysis. Patients treated for 24 weeks were excluded. The main endpoint was sustained virologic response 12 weeks after the end of treatment (SVR12), and secondary endpoint was SVR24.
Results. A total of 515 patients were included (aged 55.52±8.97 years). GT1: patients treated with simeprevir + sofosbuvir (SIM + SOF), ledipavir (LDV)/SOF and paritaprevir/ritonavir/ombitasvir + dasabuvir (PTV/r/OBV + DSV) ± RBV had a SVR12 of 93.59% (190/203), 98.82% (N=84/85), 94.28% (66/70), respectively. Regarding daclatasvir (DCV) + SOF and SIM + DCV, everybody (19/19) and 87.5% (7/8) got SVR12, respectively. GT2: 71.42% (N=10/14) of patients achieved SVR12, concretely, SOF + RBV had a SVR12 75% (N=6/8). GT3: 43.75% (N=7/16), 90% (N=9/10) and 95% (N=19/20) of patients treated with LDV/SOF, LDV/SOF + RBV and SOF + DCV obtained SVR12, respectively. GT4: patients treated with LDV/SOF, SIM + SOF and PTV/r/OBV ± RBV had a SVR12 rate of 100% (21/21), 91.67% (22/24) and 92% (23/25), respectively. All patients that got SVR12 achieved SVR24.
Conclusion. Our study confirmed the efficacy data reported in clinical trials in a cohort of patients with GT1-4 and a wide range of basal characteristics.

Rev Esp Quimioter 2018; 31(3):226-236 [Full-text PDF]

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Rev Esp Quimioter 2018; 31(3):209-216

Appropriateness of antimicrobial prescriptions in the emergency department of a tertiary hospital

LUCIA YUNQUERA-ROMERO, IGNACIO MÁRQUEZ-GÓMEZ, ARACELI HENARES-LÓPEZ, MARÍA JOSÉ MORALES-LARA, CARMEN GALLEGO FERNÁNDEZ, ROCÍO ASENSI-DÍEZ

Background. Antibiotics are widely prescribed in the Emergency Department (ED), representing 26-62% of outpatient antibiotic prescriptions. Around 40% of antibiotic prescriptions in hospitalized patients are inappropriate or unnecessary. The aim of the study was to assess the appropriateness of antibiotic prescriptions according to local empirical antibiotic treatment guidelines, in the ED of a tertiary hospital.
Material and methods. Observational, retrospective study including patients attending the ED in November 2016, with an antibiotic prescription, excluding those from residents.
Results. A total of 676 patients were included, 57.1% women, mean age 47.4 ± 21.2 years. Patient’s diagnoses were 27.2% urinary tract infections (UTI), 24.1% lower respiratory tract infections, 15.4% skin and soft tissue infections (SSTI), 13.8% upper respiratory tract infections, 11.8% oral infections, 2.7% genital/sexually transmitted infections, 1.6% gastrointestinal infections, 0.3% ocular infections and 3.1% other. The most prescribed antibiotic families were: 44.1% penicillins, 21.3% fluoroquinolones. The most prescribed antibiotics were: fosfomycin trometamol in UTI (32.1%), levofloxacin in lower respiratory tract (46.2%) and amoxicillin/clavulanate in oral infections (71.6%), SSTI (62.5%) and upper respiratory tract (46.6%). In 56.8% (384) of the prescriptions antibiotics were indicated. An appropriated antibiotic was selected in 62% (238) of the prescriptions. Appropriated dosage and duration were selected in 82.8% (197) and 45.4% (108) of the prescriptions, respectively.
Conclusions. Appropriateness of antibiotic prescriptions was low, mainly due to an overuse of antibiotics when not indicated, broad spectrum and incorrect treatment duration. These data reinforce the need to enhance adherence to local empirical antibiotic treatment guidelines by developing an antimicrobial stewardship program in the ED.

Rev Esp Quimioter 2018; 31(3):209-216 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(3):217-225

Bacterial osteomyelitis: microbiological, clinical, therapeutic, and evolutive characteristics of 344 episodes

ELENA GARCÍA DEL POZO, JULIO COLLAZOS, JOSÉ ANTONIO CARTÓN, DANIEL CAMPORRO, VÍCTOR ASENSI

Introduction. Osteomyelitis is a difficult-to-cure infection, with high relapse rate despite adequate therapy. Large published osteomyelitis series in adults are rare.
Material and methods. A total of 344 adult osteomyelitis patients were studied and followed > 12 months after hospital discharge. Demographic, microbiological, clinical, therapeutic and outcome data were analyzed.
Results. Mean age was 52.5 ± 18.3 years and 233 (67.7%) were male. Main osteomyelitis types were post-surgical (31.1%), post-traumatic (26.2%) and hematogenous (23%). Tibia (24.1%) and femur (21.8%), and methicillin-susceptible S. aureus (29.6%) were the most commonly involved bone and bacteria, respectively. Median follow-up was 12.0 (IQR 0-48) months. Inflammatory markers were increased in 73.6%. Overall, patients were treated by IV and oral routes with one (IV: 44.5%, oral: 26.7%), two (IV: 30.1%, oral: 21.8%) or ≥ 2 (IV: 15.2%, oral: 6.1%) antibiotics. Median duration on IV/oral antimicrobials was 28.0 (IQR 24-28) and 19.5 (IQR 4-56) days, respectively. Anti-staphylococcal β-lactams cloxacillin/cefazolin (19.2%) and ciprofloxacin (5.5%) were the most frequently used IV and orally, respectively. Overall 234 (68.0%) underwent surgery, 113 (32.8%) debridement, 97 (27.4%) debridement + muscle flap and 24 (7%) amputation. At the end of follow-up 208 patients (60.6%) did not have relapsed. Operated patients had significantly less relapses (p<0.0001). A total of 23 (6.7%) died, 11 (3.2%) by infectious complications and 48 (14%) were lost in the follow-up.
Conclusions. Osteomyelitis is due to different causes complicating its therapy. Risk factors or causal microorganism could influence its treatment and outcome. Aggressive surgery along with adequate antimicrobial therapy are mandatory for cure.

Rev Esp Quimioter 2018; 31(3):217-225 [Full-text PDF]

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Rev Esp Quimioter 2018; 31(3):263-267

Evaluation of a PCR-multiplex technique for the rapid diagnosis of bacteriemia

Mª FÁTIMA LÓPEZ-FABAL, JOSÉ LUIS GÓMEZ-GARCÉS, MARTA LÓPEZ LOMBA, MARIO RUIZ BASTIÁN

Introduction. Rapid and safe diagnosis of bacteremia is a continuous challenge in clinical microbiology. In this work, we evaluated a multiple PCR system that identifies 23 common pathogens as well as the production of 3 resistance mechanisms potentially present in them.
Methods. During a period of 2 months the positive blood cultures were processed in the usual way for identification and determination of their antimicrobial sensitivity. At the same time were incorporated into FilmArray panels.
Results. The agreement between two methods for bacterial identification was 100%. The time of obtaining the results by the molecular technique did not exceed 1 hour 15 minutes and in 7 cases of the 21 studied (33%) a modification of the empirical therapy was carried out.
Conclusions. The implementation of rapid techniques such as multiple PCR offers a fast, reliable and easy to perform diagnosis in the therapeutic management of sepsis.

Rev Esp Quimioter 2018; 31(3):263-267 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(3):257-262

Clinical significance and risk factors for multidrug resistant Enterobacteriaceae colonization

ANTONIO PADILLA-SERRANO, JAIME JOSÉ SERRANO-CASTAÑEDA, RAFAEL CARRANZA-GONZÁLEZ, MARÍA PILAR GARCÍA-BONILLO

Objective. To identify the main risk factors of rectal colonization by multidrug resistant Enterobacteriaceae (MRE), and their clinical impact.
Methods. An observational, prospective cohort study was carried out, between April 2016 and June 2017, where every Monday of each week rectal samples were taken from all the patients admitted at that moment in the Intensive Care Unit. We performed a descriptive analysis of all the variables collected during the study and a multivariate logistic regression analysis to determine the independent association of carriers of MRE against non-carriers and several possible risk factors.
Results. During the study period, rectal samples were collected from 208 patients. Of the 208, 30 were carriers of MRE, with a mean age of 64.3 years and a mean score of APACHE II (Acute Physiology and Chronic Health Evaluation II) of 20.6 points. 70% of the patients with MRE had a positive result in the first rectal sample. The variables that were associated with an increased risk of rectal colonization by EMR in the regression analysis were the administration of antibiotics in the previous month (OR 5.2, 95% CI 1.71-15.79) and post-surgical patients (OR 3.8; IC95% 1.51 – 9.51). Although patients with EMR had more frequent infections by these bacteria, no differences were observed in mortality between the two groups.
Conclusions. Post-surgical patients admitted to the ICU and those who received antibiotic treatment in the previous month have a higher probability of colonization due to MRE. The colonized patients presented more frequent infections by MRE although it was not associated to a higher mortality.

Rev Esp Quimioter 2018; 31(3):257-262 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(3):278-281

Turicella otitidis, contributions to its role in the etiology of ear infections

MÓNICA DE FRUTOS, LUIS LÓPEZ-URRUTIA, ROSA ARAGÓN, ANA MARÍA VEGAS, MARTA VÁZQUEZ, JOSÉ MARÍA EIROS BOUZA

Introduction. Turicella otitidis is a gram-positive bacillus coryneforme described, after 16S RNA sequencing, in 1994 by Funke et al as a microorganism involved in otitis media, and it is in health conditions a habitual colonizer of the external auditory canal. Since its description, more than twenty years ago, few cases of otitis related to or directly attributed to this microorganism have been published.
Methods. Description of a case of mastoiditis that required surgery and other cases of otic pathology in which T. otitidis was isolated, in the second semester of 2017 in our institution. They were reported only when they grew in pure culture. The identification was made by mass spectrophotometry and an antibiogram was performed
Results. In our institution in the second half of 2017, 5 cases of otitis media were documented, some of them complicated, in which T. otitidis was isolated. The most of patients were children with recurrent otic pathology, and in some cases the sample was taken before the administration of antibiotics
Conclusions. Since the inclusion of new vaccines that protect against microorganisms typically causing otitis media, is possible there are a change in the etiology of this disease and that microorganisms anecdotally isolated until now have become protagonists. The improvement in the microbiological identification provided by tools such as mass spectrometry will help to clarify if there are or not a change in the etiology of these diseases.

Rev Esp Quimioter 2018; 31(3):278-281 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(3):203-208

An historical, sociocultural view and in the fiction literature of Bacillus anthracis  cases by shaving brushes

EMMA VÁZQUEZ-ESPINOSA, CLAUDIO LAGANÀ, FERNANDO VAZQUEZ

In the period from 1915 to 1924 anthrax outbreaks were described by Bacillus anthracis due to the contamination of razor brushes that reached Europe and the United States from areas such as Japan, China or Russia. The brushes were made with badger hair, and then, to reduce the cost with horse hair and other animals. World War I supoosed that the traffics of these brushes, that passed through Europe, changed and the processes of sterilization of the same were deficient giving rise to these outbreaks, that in a percentage of 20% produced the death of the users. The impact of the fashion of wearing a beard, the presence of these cases in the press, in the society of that period, and literature are studied through the work of Agatha Christie who wrote, in 1936, the Hercules Poirot´s novel Cards on the table, and where she describes the murder of one of the characters with the shaving brush contaminated with Bacillus anthracis spores.

Rev Esp Quimioter 2018; 31(3):203-208 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(2): 186-202

Recommendations for the care of patients with community-acquired pneumonia in the Emergency Department

AGUSTÍN JULIÁN-JIMÉNEZ, INMACULADA ADÁN VALERO, ALICIA BETETA LÓPEZ, LUIS MIGUEL CANO MARTÍN, OLGA FERNÁNDEZ RODRÍGUEZ, RAFAEL RUBIO DÍAZ, Mª ANTONIA SEPÚLVEDA BERROCAL, JUAN GONZÁLEZ DEL CASTILLO, FRANCISCO JAVIER CANDEL GONZÁLEZ Y EN NOMBRE DEL GRUPO NAC (NEUMONÍA ADQUIRIDA EN LA COMUNIDAD) DEL GRUPO INFECCIONES EN URGENCIAS-CÓDIGO SEPSIS DE LA RED DE EXPERTOS Y PROFESIONALES DE URGENCIAS DEL SESCAM (SERVICIO DE SALUD DE CASTILLA LA MANCHA) Y DE INFURG-SEMES (GRUPO DE TRABAJO DE INFECCIONES DE LA SOCIEDAD ESPAÑOLA DE MEDICINA DE URGENCIAS Y EMERGENCIAS)

The incidence of community-acquired pneumonia (CAP) ranges from 2-15 cases / 1,000 inhabitants / year, being higher in those older than 65 years and in patients with high co-morbidity. Around 75% of all CAP diagnosed are treated in the Emergency Department (ED). The CAP represents the main cause for sepsis and septic shock in ED, and the most frequent cause of death and admission to the Intensive Care Unit (ICU) due to infectious disease. Overall mortality is 10-14% according to age and associated risk factors. Forty to 60% of CAP will require hospital admission, including observation units (with very variable ranges from 22-65% according to centers, seasonal of the year and patients´ characteristics). Between the admissions, 2-10% will be in the ICU. All of previously mentioned reflects the importance of the CAP in the ED, as well as the “impact of the emergency care on the patient with CAP”, as it is the establishment where the initial, but key decisions, are made and could condition the outcome of the illness.
It is known the great variability among physicians in the diagnostic and therapeutic management of CAP, which is one of the reasons that explains the great differences in the admission rates, achievement of the microbiological diagnosis, request for complementary studies, the choice of antimicrobial treatment, or the diversity of applied care. In this sense, the implementation of clinical practice guidelines with the use of the severity scores and the new tools available, such as biomarkers, can improve patient care with CAP in ED. Therefore, a multidisciplinary group of emergency professionals and specialists involved in the care process of CAP has designed a guideline with several recommendations for decisions-making during the key moments in patients with CAP attended in the ED.

Rev Esp Quimioter 2018; 31(2): 186-202 [Texto completo PDF]

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