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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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Rev Esp Quimioter 2018; 31(2): 160-163

First clinical isolation report of Shewanella algae from the stools of a patient with acute enteritis in Spain

ELEAZAR FERNÁNDEZ-FERNÁNDEZ, ALBERTO J. MARTÍN-RODRÍGUEZ, MARIANO HERNÁNDEZ, JOSÉ MARÍA NAVARRO-MARÍ, UTE RÖMLING, JOSÉ GUTIÉRREZ-FERNÁNDEZ

We report a case of acute enteritis caused by Shewanella algae in a cirrhotic patient. Biochemical identification systems revealed to be insufficient to identify the Shewanella isolate at the species level, thus requiring 16S rRNA and gyrB partial gene sequencing. Even if co-infection by Clostridium difficile could not be ruled out, this is, to our knowledge, the first report of acute enteritis caused by Shewanella algae in Europe.

Rev Esp Quimioter 2018; 31(2): 160-163 [Full-text PDF]

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Rev Esp Quimioter 2018; 31(2): 146-151

Clinical and microbiologic characteristics of pleuro-pulmonary infection due to Streptococcus intermedius

FERNANDO COBO, ANTONIO SAMPEDRO, JAVIER RODRÍGUEZ-GRANGER, LUIS ALIAGA-MARTÍNEZ, JOSÉ MARÍA NAVARRO-MARÍ

The clinical and microbiological characteristics of pleuro-pulmonary infection (PPI) caused by Streptococcus intermedius is described, including 6 cases in the literature and 9 cases handled at the present centre. Out of the 15 patients, 12 were male; mean age at diagnosis was 62.06 ± 15 years. Twelve had risk factors for S. intermedius infection such as alcoholism in 5 (35.7%) patients, periodontal disease in 3 (24.6%) cases, chronic obstructive pulmonary disease in 3 (24.6%), and diabetes mellitus in 2 (14.2%). Cough was present in 12 (80%) patients and chest pain and dyspnea in 9 (60%). The mean diagnosis interval was 34 days. The diagnosis was obtained from pleural fluid aspirate in 13 (86.6%) cases and from biopsy/tissue samples in 2. The most frequently antimicrobials used for treatment were ceftriaxone + levofloxacin. Ten patients cured with a combination of medical and surgical treatment and 2 patients died as a consequence of infection. The incidence of PPI caused by S. intermedius is increasing in our health area; drainage along with antibiotic therapy is recommended for treatment.

Rev Esp Quimioter 2018; 31(2): 146-151 [Full-text PDF]

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Rev Esp Quimioter 2018; 31(2): 123-130.

Nosocomial infections caused by multiresistant Pseudomonas aeruginosa (carbapenems included): predictive and prognostic factors. A prospective study (2016-2017)

ALICIA HERNÁNDEZ, GENOVEVA YAGÜE, ELISA GARCÍA VÁZQUEZ, MARINA SIMÓN, LAURA MORENO PARRADO, MANUEL CANTERAS, JOAQUÍN GÓMEZ

Introduction. Pseudomonas aeruginosa is one of the major pathogens causing hospital-acquired infections. In recent years, antimicrobial resistance is increasing and multidrug resistant (MDR) and extremely drug resistant (XDR) isolates have been associated with an increase of mortality. The aim of this study is to assess the clinical significance and analyze predictors and prognostic factors.
Methods. Prospective case-control non-paired study involving 64 patients with P. aeruginosa nosocomial infection, 32 caused by susceptible P. aeruginosa and 32 by MDR/XDR including to carbapenems (XDR-C) strains, admitted at a third level hospital. The follow-up period was till hospital discharge or death and at 30 days after discharge. For all patients, clinical epidemiology and microbiological data were analyzed.
Results. The incidence of MDR/XDR-C strains was 2.3 per 1000 admissions. Ten of which were VIM metallo-β-lactamase–producing. Independent predictor factors associated with MDR/XDR-C infections were: previous ICU or Resuscitation unit admission (OR 14.01; IC 95% 2.105-93.297) appearance >20 days after admission (OR 29.826; IC 95% 4.783-185.997) and leukocytosis (OR 10.0190; IC 95% 1.842-56.369). However, there were not statistically significant differences in clinical severity or mortality between both groups.
Conclusión. The major risk factors associated with MDR/XDR-C infections were previous ICU or Resuscitation unit admission, appearance >20 days after admission and leukocytosis. MDR/XDR-C infections were not associated to increased mortality.

Rev Esp Quimioter 2018; 31(2): 123-130. [Texto completo PDF]

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