EPICO 2.0 PROJECT. Development of educational therapeutic recommendations using the DELPHI technique on invasive candidiasis in critically ill adult patients in special situations                                 
 

RAFAEL ZARAGOZA, RICARD FERRER, EMILIO MASEDA, PEDRO LLINARES, ALEJANDRO RODRIGUEZ ON BEHALF OF THE EPICO PROJECT GROUP               

Introduction. Although there has been an improved management of Invasive Candidiasis in the last decade, still controversial issues remain, especially in different therapeutic critical care scenarios.
Objectives. We sought to identify the core clinical knowledge and to achieve high agreement recommendations required to care for critically ill adult patients with Invasive Candidiasis for antifungal treatment in special situations and different scenarios.
Methods. Second Prospective Spanish survey reaching consensus by the Delphi technique, conducted anonymously by electronic e-mail in the first phase to 23 national multidisciplinary experts in invasive fungal infections from five national scientific societies including Intensivists, Anesthesiologists, Microbiologists, Pharmacologists and Infectious disease specialists, answering 30 questions prepared by a coordination group after a strict review of literature in the last five years. The educational objectives spanned four categories, including peritoneal candidiasis, immunocompromised patients, special situations and organ failures. The agreement among panellists in each item should be higher than 75% to be selected. In a second phase, after extracting recommendations from the selected items, a meeting was heldwith more than 60 specialists in a second round invited to validate the preselectedrecommendations.
Measurements and Main Results. In the first phase, 15 recommendations were preselected (peritoneal candidiasis (3), immunocompromised patients (6), special situations (3) and organ failures (3)). After the second round the following 13 were validated: Peritoneal candidiasis (3): Source control and early adequate antifungal treatment is mandatory; empirical antifungal treatment is recommended in secondary nosocomial peritonitis with Candida spp colonization risk factors and in tertiary peritonitis. Immunocompromised patients (5): Consider hepatotoxicity and interactions before starting antifungal treatment with azoles in transplanted patients; treat candidemia in neutropenic adult patients with antifungal drugs at least 14 days after the first negative blood culture and until normalization of neutrophil count is achieved. Caspofungin, if needed, is the echinocandin with most scientific evidence to treat candidemia in neutropenic adult patients; Caspofungin is also the first choice drug to treat febrile candidemia; in neutropenic patients with candidemia remove catheter. Special situations (2): In moderate hepatocelular failure, patients with invasive candidiasis use echinocandins (preferably low doses of anidulafungin and caspofungin) and try to avoid azoles; in case of possible interactions review all of the drugs involved and preferably use Anidulafungin. Organ failures (3): Echinocandins are the safest antifungal drugs; reconsider the use of azoles in patients under renal replacement therapy; all of the echinocandins are accepted for the treatment of patients under continuous renal replacement therapy and do not require dosage adjustment.
Conclusions. Treatment of Invasive Candidiasis in ICU patients requires a broad range of knowledge and skills as summarized in our recommendations. These recommendations may help to optimize the therapeutic management of these patients in special situations and different scenarios and improve
their outcome based on the DELPHI methodology.

Rev Esp Quimioter 2014:27(3):196-212 [pdf]

Prospective follow-up of results of tuberculosis treatment                                 
 

MARTA MORENO-GÓMEZ, MONTSERRAT ALONSO-SARDÓN, HELENA IGLESIAS-DE-SENA, LUCIANA LUCENA ARANHA DE MACÈDO               

Objective. The aim of the study was to analyze tuberculosis treatment outcomes in a health area of the National Health System.
Material and Methods. Analytical cohort study of tuberculosis’ cases treated in the hospital care of the health area of Salamanca (Spain) 6 months. The clinical record constituted the basic source of data, whose information was complemented by a clinical interview to the patient. The microbiological records were additionally used for classifying the therapeutic outcomes in satisfactory outcome (SO), potentially unsatisfactory outcome (PUO) and death. A total of 146 patients met the inclusion criteria; 108 patients were interviewed. Their average age was 49 years. Out of them, 29.6% (32/108) showed some social risk factor (SRF).
Results. The SO level was 55.6% (IC 95%: 55.6±9); the variables associated with the SO were young elderly patients, living in family and patterns of 6 months. The PUO proportion stood at 40.7% (IC 95%: 40.7±9); the variables which increased the PUO probability were adulthood, residing in other provinces, living alone, comorbidity, human immunodeficiency virus (HIV), alcoholism and social maladjustment. The variables included in the final model for PUO in logistic regression were adult, comorbidity and SFR, while the institutional conditions associated the mortality.
Conclusions. The SO rates can be improved. The PUO level is conditioned by high loss rates, 31.5% (95% CI: 31.5 ± 9), so measures should be established for reduction and improve the effectiveness of the overall treatment.

Rev Esp Quimioter 2014:27(4):244-251 [pdf]

Trend in the susceptibility of the most frequent bacterial pathogens isolated at Hospital General La Mancha Centro over 2010-2012 period                                 
 

MARÍA ÁNGELES ASENCIO, MARÍA HUERTAS, RAFAEL CARRANZA, MARÍA FRANCO, JESÚS CASTELLANOS, JOSÉ RAMÓN BARBERÁ, MARÍA DEL CARMEN CONDE, JOSÉ MARÍA TENÍAS              

Introduction. Our objective was to determine the trend of the antimicrobial susceptibility of the most common bacterial
pathogens isolated in La Mancha Centro Hospital (MCH) between 2010-2012.
Material and methods. Isolates of Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa from patients admitted to MCH were studied. These data and their antibiotic susceptibility were obtained from the database OBSERVA (BioMérieux).
Results. The percentages of susceptibility for S. aureus were: 50% methicillin-resistant-S. aureus (MRSA) (higher co-resistance to erythromycin and levofloxacin), 46% erythromycin, 73% clindamycin, 45% levofloxacin, 99% rifampin and 100% cotrimoxazole, glycopeptides, linezolid and daptomycin. Increased resistance in ICU was observed (63% MRSA), with 50% of S. aureus (susceptible and methicillin-resistant strains) with vancomycin MIC values ≥ 0.5 mg/L. E. coli susceptibility: 62% amoxicillin-clavulanate, 55% ciprofloxacin, 60% cotrimoxazole, 84% gentamicin and 95% fosfomycin. K. pneumoniae susceptibility: 74% amoxicillin-clavulanate, 71% ciprofloxacin, 78% cotrimoxazole, 94% gentamicin and 87% fosfomycin. The percentage of BLEE strains was 17% and 21% for E. coli and K. pneumoniae, respectively, without detection of resistance to carbapenems. P. aeruginosa susceptibility: 80% ceftazidime and carbapenems, 63% ciprofloxacin and higher than 90% aminoglycosides. A decreasing trend of susceptibility to ceftazidime and carbapenems was observed in ICU and increasing trend to ciprofloxacin.
Conclusions. Resistance percentages were higher in ICU than in the rest of the hospital, highlighting 63% of MRSA strains. Our percentage of BLEE and MRSA strains were higher than the Spanish media. Rifampicin and cotrimoxazole maintain good susceptibility to S. aureus, fosfomycin and aminoglycosides to Enterobacteriaceae and carbapenems to P. aeruginosa.

Rev Esp Quimioter 2014:27(4):261-268 [pdf]

Influenza surveillance by molecular methods

A. TENORIO, J. M. EIROS, E. RODRÍGUEZ, J. F. BERMEJO, M. DOMÍNGUEZ, T .VEGA, J. CASTRODEZA, R. ORTIZ

 

Introduction: Our objective was to evaluate the application of molecular techniques in the surveillance of influenza, and to describe clinical and epidemiological characteristics of cases diagnosed in 2007-2008 and2008-2009 seasons.

Methods: We analyzed 183 pharyngeal swabs from the same number of patients referred to the virology laboratory of the Sentinel Physician Network of Castilla y Leon, the study of influenza viruses by shell-vial technique and RT-PCR capable of detecting multiple Simultaneously, influenza virus A, B, C, respiratory syncytial virus A, B and adenovirus.

Results: Using cell culture were isolated 17 influenza A viruses and 19 influenza B viruses (19.7% of total). By multiple RT-PCR, was detected 49 influenza A virus, 29 influenza B virus, an influenza virus C, 3 syncytial virus type A and other B and 6 adenoviruses (44.3% of total). All influenza viruses isolated in cell culture was detected by RT-PCR. RT-PCR by 5 co-infections were detected, which represented a 6.25% of co-infections on the whole of positive samples. The average age of patients was 29 years (SD = 21.07). The proportion of women and men accounted for 43.7% and 56.3% respectively. The number of cases diagnosed in relation to age follows a pattern of negative linear correlation.

Conclusions: RT-PCR is revealed as an useful tool for epidemiological surveillance of influenza, allowing also to detect viral subtypes along with other viruses involved in respiratory infections.

Rev Esp Quimioter 2009:22(4):214-220 [pdf]