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Rev Esp Quimioter 2018; 31(4): 316-322

Assessment of the severity scores in patients included in a sepsis code in an Emergency Departament

ALBERTO REDONDO-GONZÁLEZ, MARÍA VARELA-PATIÑO, JESÚS ÁLVAREZ-MANZANARES, JOSÉ RAMÓN OLIVA-RAMOS, RAÚL LÓPEZ-IZQUIERDO, CARMEN RAMOS-SÁNCHEZ, JOSÉ MARÍA EIROS

Objectives. The objective of the study is to determine the usefulness of the SOFA (Sequential Organ Failure Assessment), quick SOFA (qSOFA), LODS (Logistic Organ Dysfunction System) and EWS (Early Warning Score) scores to predict in-hospital mortality among septic patients attended in the emergency department; to evaluate what factors are associated with mortality; and develop a predictive model of in-hospital mortality.
Material and methods. Retrospective study including patients over 14 years of age included in the sepsis code of an Emergency Department of a University Hospital between November 2013 and September 2015. Demographic variables, hemodynamic and analytical variables, and in-hospital mortality were collected to obtain qSOFA, SOFA, LODS, EWS scores. Receiver operating characteristic curves were constructed for each score. Logistic regression was used to evaluate the probability of in-hospital mortality.
Results. A total of 349 patients were analyzed, median age 72.7 (range 86), males: 54.4%. The in-hospital mortality was 21.8%. AUC obtained: LODS: 0.73 (IC 95% 0.67-0.80; p<0.001), EWS: 0.73 (IC 95% 0.65-0.81; p<0.001), SOFA: 0.72 (IC 95% 0.65- 0.78; p<0.001), qSOFA: 0.67 (IC 95% 0.58-0.76; p<0.001). After the multivariate analysis, these were the independent factors associated with in-hospital mortality: Oxygen saturation ≤92%, Glasgow coma score <14, lactate ≥2mmol/L (p<0.05). Two prognostic models were generated: MPRO1: age, oxygen saturation ≤92% and Glasgow coma score <14, AUC: 0.78 (IC 95% 0.72-0.84; p<0.001) and MPRO2 formed by the previous ones and lactate ≥2mmol/L, AUC: 0.82 (IC 95% 0.76-0.87; p<0.001)
Conclusions. SOFA score and the new developed scores could be useful in asses the risk of in-hospital mortality in patients included in the sepsis code.

Rev Esp Quimioter 2018; 31(4): 316-322 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(4): 298-315

Current aspects in sepsis approach. Turning things around

FRANCISCO JAVIER CANDEL, MARCIO BORGES SÁ, SYLVIA BELDA, GERMÁN BOU, JOSÉ LUIS DEL POZO, ORIOL ESTRADA, RICARD FERRER, JUAN GONZÁLEZ DEL CASTILLO, AGUSTÍN JULIÁN-JIMÉNEZ, IGNACIO MARTÍN-LOECHES, EMILIO MASEDA, MAYRA MATESANZ, PAULA RAMÍREZ, JOSÉ TOMÁS RAMOS, JORDI RELLO, BORJA SUBERVIOLA, ALEJANDRO SUÁREZ DE LA RICA, PABLO VIDAL

The incidence and prevalence of sepsis depend on the definitions and records that we use and we may be underestimating their impact. Up to 60% of the cases come from the community and in 30-60% we obtain microbiological information. Sometimes its presentation is ambiguous and there may be a delay in its detection, especially in the fragile population. Procalcitonin is the most validated biomarker for bacterial sepsis and the one that best discriminates the non-infectious cause. Presepsin and pro-adrenomedullin are useful for early diagnosis, risk stratification and prognosis in septic patients. The combination of biomarkers is even more useful to clarify an infectious cause than any isolated biomarker. Resuscitation with artificial colloids has worse results than crystalloids, especially in patients with renal insufficiency. The combination of saline solution and balanced crystalloids is associated with a better prognosis. Albumin is only recommended in patients who require a large volume of fluids. The modern molecular methods on the direct sample or the identification by MALDI-TOF on positive blood culture have helped to shorten the response times in diagnosis, to optimize the antibiotic treatment and to facilitate stewardship programs. The hemodynamic response in neonates and children is different from that in adults. In neonatal sepsis, persistent pulmonary hypertension leads to an increase in right ventricular afterload and heart failure with hepatomegaly. Hypotension, poor cardiac output with elevated systemic vascular resistance (cold shock) is often a terminal sign in septic shock. Developing ultra-fast Point-of-Care tests (less than 30 minutes), implementing technologies based on omics, big data or massive sequencing or restoring “healthy” microbiomes in critical patients after treatment are the main focuses of research in sepsis. The main benefits of establishing a sepsis code are to decrease the time to achieve diagnosis and treatment, improve organization, unify criteria, promote teamwork to achieve common goals, increase participation, motivation and satisfaction among team members, and reduce costs.

Rev Esp Quimioter 2018; 31(4): 298-315 [Full-text PDF]

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Rev Esp Quimioter 2018; 31(4): 344-352

Vaccination of pregnant women in the Valencian Community during the 2014-15 influenza season: a multicentre study

JOSÉ TUELLS, NOELIA RODRÍGUEZ-BLANCO, JOSÉ LUIS DURO TORRIJOS, RAFAEL VILA-CANDEL, ANDREU NOLASCO BONMATI

Background. To study influenza vaccination uptake in pregnant women from three Health Departments in the Valencian Community (Spain) during the 2014-15 flu season, to identify degree of knowledge, sources of information and attitudes toward immunization against influenza.
Methods. Multicentre cross-sectional descriptive study during the 2014-15 vaccination campaign. Vaccine coverage was determined using the Nominal Vaccination Registry (NVR). Subsequently, a telephone survey was carried out on a sample of vaccinated and unvaccinated postpartum women.
Results. The NVR had information on 934 (59.5%) out of 1,569 postpartum women; distribution per Health Departments was: 420 (44.9%), 161 (17.2%) and 353 (37.8%) in La Ribera, Torrevieja and Elx-Crevillent respectively. Vaccine uptake was 27.9% (n = 261). According to the “Country of Origin” variable, 77.5% (n = 724) of women were Spanish, with a vaccination rate of 26.7% (n = 193), compared to 22.5% (n = 210) who were non-Spanish, with a rate of 32.4% (n = 68). The main source of information was midwives for 83.7% (n = 159) of vaccinated pregnant women and for 44.6% (n = 127) of non-vaccinated women. The main reasons for vaccine refusal were lack of awareness (29.5%, n = 84) and not considering it necessary (25.6%, n = 73).
Conclusion. Despite their high willingness to be vaccinated after receiving information about the flu vaccine, the vaccination coverage in pregnant women studied is still low and can be improved. Health professionals need new information strategies to extend vaccine uptake to a larger number of pregnant women in Spain. Midwife advice plays an essential role in transmitting information on influenza vaccination in pregnant women and has a significant impact on uptake.

Rev Esp Quimioter 2018; 31(4): 344-352 [Full-text PDF]

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Rev Esp Quimioter 2018; 31(4): 323-328

Inpatient candiduria: etiology, susceptibility to antifungal drugs and risk factors

GEMMA JIMÉNEZ-GUERRA, ISABEL CASANOVAS MORENO-TORRES, MIGUEL GUTIÉRREZ-SOTO, FERNANDO VAZQUEZ-ALONSO, ANTONIO SORLÓZANO-PUERTO, JOSÉ MARÍA NAVARRO-MARÍ, JOSÉ GUTIÉRREZ-FERNÁNDEZ

Introduction. Candida could become the second most frequent cause of nosocomial urinary tract infection. Although Candida albicans is the most important species, others have arisen as emerging pathogens. The aim of this study was to analyze the presence of candiduria in inpatients.
Material and methods. We performed a retrospective study of Candida isolates from adult inpatient urocultures over five years, gathering and tabulating data on: the species; susceptibility to fluconazole, amphotericin B, and voriconazole (Vitek2, BioMerieux); presence of catheter; hospital department of origin; and patient age and sex.
Results. We detected 289 yeast episodes, observing an annual increase: 134 (46.4%) were non-C. albicans yeasts, with 57 (19.7%) being Candida glabrata, 37 (12.8%) Candida tropicalis, 25 (8.6%) Candida parapsilosis, and 10 (3.5%) Candida lusitaniae. Most isolates derived from catheterized (240, 83.0%) and Internal Medicine Department (118, 40.8%) patients, observing an annual increase; 152 (52.6%) isolates were from males, and the mean age was >65 years. Susceptibility to antifungals was >85%.
Conclusions. Inpatient urocultures should include data on the presence of Candida, which is more prevalent in Internal Medicine Department inpatients, in those with urinary catheter, and in over 65-year-olds. Almost half of the isolates were non-C. albicans yeasts, and we recommend complete identification of the species involved.

Rev Esp Quimioter 2018; 31(4): 323-328  [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(3):274-277

Colonization rates by Streptococcus agalactiae in Spanish and foreign pregnant women in the Fuenlabrada University Hospital

EVA MARÍA ÁLVAREZ-SANTÁS, JERÓNIMO JAQUETI-AROCA, ISABEL GARCÍA-ARATA, LAURA MOLINA-ESTEBAN, JESÚS GARCÍA-MARTÍNEZ, SANTIAGO PRIETO-MENCHERO

Objectives. In pregnant women, the rectovaginal colonization by Streptococcus agalactiae (GBS) is related with geographic area of origin (6.5% to 36%). It was analysed GBS carriage in pregnant women in 2012-2014 in our hospital.
Material and methods. Observational retrospective study about GBS isolates from rectovaginal samples (RVS) and urine cultures of Spanish and immigrant pregnant women in 2012-2014. It was considered only a single isolation for patient. There were excluded women with GBS in urine samples of RVS study.
Results. A total of 4,648 Spanish and 1,405 immigrant women were analysed. GBS was detected in urine samples in 231 Spanish (5%) and 106 immigrant (7.6%). A total of 5,716 RVS were analysed, GBS was detected in 10.5% of Spanish women and in 18.9% of immigrant women.
Conclusions. The overall colonization in immigrant women is higher than in Spanish with the exception of Asian women. Cases of GBS detected in urine samples might serve as a possible explanation for the high rate of GBS carriage.

Rev Esp Quimioter 2018; 31(3):274-277 [Texto completo PDF]

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Rev Esp Quimioter 2018; 31(3):268-273

Achromobacter xylosoxidans bacteremia: clinical and microbiological features in a 10-year case series

EDGAR PÉREZ BARRAGÁN, JUSTO SANDINO PÉREZ, LAURA CORBELLA, MARÍA ÁNGELES ORELLANA, MARIO FERNÁNDEZ-RUIZ

Objective. The treatment of Achromobacter xylosoxidans bacteremia is challenged by antimicrobial resistance and the paucity of data. We aimed at offering a contemporary description of this uncommon entity.
Patients and methods. Retrospective case series of 13 episodes of A. xylosoxidans bacteremia diagnosed over a 10-year period (November 2007 to May 2017) in our tertiary care center.
Results. Solid organ cancer and heart failure were the most common comorbidities (4/13 [30.7%]). All but one episodes were hospital-acquired. Most patients had received previous antibiotic therapy (7/13 [53.8%]) and had a central venous catheter in place (6/13 [46.1%]). Primary and intravascular catheter were the most common sources (4/13 [30.7%] each). Meropenem was the agent with best in vitro activity (92.3% [12/13] of susceptible isolates). All-cause 30-day mortality (overall 23.1%) was higher in patients with primary bacteremia (50.0% vs. 11.1%; P-value=0.203) and prior chemotherapy (66.7% vs. 10.0%; P-value=0.108).
Conclusions. Bacteremia due to A. xylosoxidans constitutes a serious infection among immunocompromised hosts. Carbapenem-based therapy may be appropriate in most cases.

Rev Esp Quimioter 2018; 31(3):268-273 [Full-text PDF]

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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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