Rev Esp Quimioter 2017, 30(4):257-263

Impact of a stewardship program on bacteraemia in adult inpatients

ESPERANZA MERINO, ELENA CARO, JOSÉ M. RAMOS, VICENTE BOIX, ADELINA GIMENO, JUAN CARLOS RODRÍGUEZ, GERÓNIMA RIERA, PATRICIO MÁS-SERRANO, JOSÉ SANCHÉZ-PAYA, SERGIO REUS, DIEGO TORRÚS, JOAQUÍN PORTILLA

Background. Bloodstream infections (BSIs) are associated with considerable morbidity and mortality among inpatients. The aim of this study was to evaluate the impact of a stewardship program on clinical and antimicrobial therapy-related outcomes in patients with bacteraemia.
Methods. Single-centre, before-and-after quasi-experimental study in adult inpatients. Over 1 January 2013 to 31 June 2013 all patients aged 18 years or older with a bacteraemia (interven-tion group, N=200) were compared to a historical cohort (1 Janu-ary 2012 to 31 December 2012) (control group, N=200).
Results. Following blood culture results and adjusting for potential confounders, the stewardship program was associated with more changes to antibiotic regimens (adjusted odds ratio [ORa]: 4.6, 95% CI 2.9, 7.4), more adjustments to antimicrobial therapy (ORa: 2.4, 95% CI 1.5, 3.8), and better source control in the first five days (ORa 1.6, 95% CI: 1.0, 2.7). In the subgroup that initially received inappropriate empiric treatment (n=138), the intervention was associated with more antibiotic changes (OR: 3.9, 95% CI: 1.8, 8.5) and a better choice of definitive antimicrobial therapy (OR 2.3 95% CI: 1.2, 4.6). There were also more antibiotic changes in the subgroups with both Gram-negative (OR: 2.8, 95% CI: 1.6, 4.9; n=217) and Gram-positive (OR: 4.6, 95% CI: 1.8, 9.9; n=135) bacteraemia among those receiving the intervention, while the Gram-positive subgroup also received more appropriate definitive antimicrobial therapy (OR: 3.9, 95% CI: 1.8, 8.8).
Conclusion. The stewardship program improved treatment of patients with bacteraemia and appropriateness of therapy.

Rev Esp Quimioter 2017; 30(4):257-263 [pdf]

/por

Rev Esp Quimioter 2017, 30(4):293-296

 

Post-exposure prophylaxis against HIV, do we use our resources appropriately?                     

ROSA ESCUDERO-SÁNCHEZ, CHRISTIAN J. KURT MEIER-DE-TABOADA, EMMA BARTOLOME-GARCÍA, PATRICIA M. RODRÍGUEZ-DE-BETHENCOURT-SANJUAN, JUAN EMILIO LOSA-GARCÍA

Introduction. Post-exposure prophylaxis (PEP) against human immunodeficiency virus can be occupational, non-occupational or vertical transmission. The aim of our study was to analyse the indication and treatment carried out in a hospital.
Methods. Retrospective observational study that included all patients who received PEP between 2006 and 2014. The project was approved by the Committee for Ethics in Clinical Research.
Results. We evaluated 54 PEP, which were started at 11.8 hours’ average. The antiretroviral drugs were adequately chosen, but the duration pattern did not adjusted to the recommendations published at that time. Tolerance was good, being gastrointestinal symptoms the most frequent adverse effects; only once was necessary to replace the pattern. There were usual losses during follow up, reaching in some subgroups 50%.
Conclusion. Indication and choice of drugs were adequate in the three kinds of contact risks, but monitoring should improve.

Rev Esp Quimioter 2017; 30(4):293-296  [pdf]

/por

Rev Esp Quimioter 2017, 30(5): 305-311

Microbiome and next generation sequencing

AVELINA SUÁREZ MOYA

The human microbiome is an internal ecosystem that refers to the community of microorganisms that populate the human body. These microorganisms are essential to support his health, because the interaction between the host immune system and microorganisms, provide the host with protection against pathogens, and contributes to the preservation of health.
Bacteriological culture has been the basis for traditional microbiology; however, most of the bacterial forms observed in nature cannot be isolated with laboratory culture methods. At present, metagenomic applies a suite of genomic technologies, where the microorganisms are identified by their genomic fingerprint.
The 16S rRNA subunit is considered as the universal target for bacterial identification from DNA with the aid of sequencing. Sanger sequencing technology had a great impact on the first generation sequencing due to its simplicity and precision. Platforms high-throughput known as second generation secuencing technologies are capable to generate hundreds of thousands of sequence reactions in a faster and economic way. However, thanks to the third generation sequencing the greatest advances in nanotechnology have been made.
Using the reference gene, the massive sequencing techniques and bioinformatics tools used for the data processing, there has been an important development of the human microbiome, achieving an unprecedented detail level on the taxonomy and microbial function. This has meant an authentic revolution not only in their knowledge but also in their involvement in the health or illness of the human being.

Rev Esp Quimioter 2017; 30(5): 305-311 [Texto completo – PDF]

/por

Rev Esp Quimioter 2017, 30(5): 341-349

Assessment of adherence to antibiotic treatment in Primary Care by determining levels of the drug using a liquid chromatography technique

PAOLA NAVARRO-GÓMEZ, ANTONIO SORLÓZANO-PUERTO, MARÍA DEL MAR OLMO-NAVAS, PABLO NIETO-GUINDO, RAMÓN DUEÑAS-ALCALÁ, JOSÉ GUTIÉRREZ-FERNÁNDEZ, ROBERTO ROMERO-GONZÁLEZ, MANUEL ÁNGEL RODRIGUEZ-MARESCA

Introduction. The lack of adherence to antibiotic treatments is a matter of special interest, which has important clinical implications, as it is associated with therapeutic failure and increased bacterial resistance causing a high sani-tary cost. The objective of our study was to assess the degree of adherence to prescribed antibiotic treatment in outpatients through the detection of these in blood, urine or sputum.
Material and methods. Concentrations of antibiotics prescribed in 39 patients (34 with clinical suspicion of urinary tract infection and 5 with clinical suspicion of low respiratory tract infection) treated in Primary Care consultations of the Sanitary District of Almería (Spain) were determined by ultra-high performance liquid chromatography coupled to tandem mass spectrometry.
Results. A 48.7% of the patients did not comply correctly with the indicated treatment due to the complete or partial omission in taking the prescribed antibiotics. This lack of adherence was independent of the age and sex of the patients, the number of daily doses of the antibiotic, and whether or not they were receiving another medication.
Conclusions. Precise analytical techniques such as liquid chromatography can be useful to detect inadequate or incomplete treatments as well as the degree of adherence of outpatients. Thus, adequate measures could be established that affect the control of therapeutic compliance.

Rev Esp Quimioter 2017; 30(5): 341-349 [Texto completo – PDF]

/por

Rev Esp Quimioter 2017, 30(5): 319-326

Adverse events related to medication in hospitals from the Valencian Community. EPIDEA Study 2005-2013

JUAN BAUTISTA MOLLAR-MASERES, JESUS MARÍA ARANAZ-ANDRÉS, JOSÉ MARÍA MARTIN-MORENO, JUAN JOSÉ MIRALLES-BUENO, JUANA REQUENA-PUCHE, HÉCTOR ROLANDO MARTÍNEZ-MOREL, MARÍA MERCEDES LUJÁN-TOLOSA

Introduction. To determine the prevalence of Adverse Events related to Medication (AEM) in hospitals of the Valencian Community in the 2005-2013 study period, and to describe the associated risk factors and their impact.
Material and methods. This study is based on data and methodology of the Study of Prevalence of Adverse Events in hospitals (EPIDEA), since its inception in 2005 until 2013. AEM produced in each year were analyzed.
Results. We identified 344 AEM that occurred in 337 patients, among 35,103 patients studied, giving a prevalence of patients with AEM of 0.96% (IC95% 0.89-1.07). The most prevalent intrinsic risk factors for AEM were hypertension, diabetes and cancer. The most prevalent extrinsic risk factors were peripheral venous catheter, urinary catheter and central venous catheter. Therapeutic groups most frequently involved were systemic antibiotics, cardiovascular drugs and antineoplastics.  The 61.17% of AEM was classified as moderate, followed by 27.18% as mild and 11.65% as severe. The 33.99% of EAM caused increase of the patient’s stay and 39.90% of EAM caused the re-entry of patient. The 58.5% of AEM were avoidable. Mild AEM were avoidable in 46.3%, moderate AEM were avoidable in 60.3% and severe AEM were in 75% (p = 0.013).
Conclusions. The prevalence of patients with AEM in hospitals of the Community of Valencia for the period 2005- 2013 was 0.96%. More than half of AEM were preventable, and preventability increases significantly with the severity of the event.

Rev Esp Quimioter 2017; 30(5): 319-326 [Texto completo – PDF]

/por

Rev Esp Quimioter 2017, 30(5): 372-378

Misconceptions of Spanish general practitioners’ attitudes toward the management of urinary tract infections and asymptomatic bacteriuria: an internet-based questionnaire study

CARLES LLOR, ANA MORAGAS, SILVIA HERNÁNDEZ, SILVIA CRISPI, JOSEP M. COTS

Introduction. The diagnosis and management of urinary tract infections (UTI) vary widely across countries and practices. The objective of this study was to gain insight into general practitioners’ (GP) perceptions on the current management of UTIs and asymptomatic bacteriuria in Spain.
Methods. Cross-sectional, internet-based questionnaire study answered from July to September 2013. GPs affiliated with the largest Spanish scientific society in primary care (Sociedad Española de Medicina Familiar y Comunitaria) were invited to participate in the study. They were asked about the tests ordered in both uncomplicated and complicated UTIs and about the management in three clinical scenarios, depicting a 50-year woman with: 1. An uncomplicated UTI, 2. A complicated UTI, and 3. An asymptomatic bacteriuria.
Results. The questionnaire was completed by 1,239 GPs (6.7%). Urine cultures were reportedly requested by 26.3% of the GPs in uncomplicated UTIs and by 71.8% of the cases corresponding to the complicated UTIs whereas it was declared that dipsticks were the preferred tests in only uncomplicated UTIs (38.2%). A total of 22% and 13.2% of the GPs stated that they would withhold antibiotic therapy in patients with low-count and high-count asymptomatic bacteriuria, respectively
Conclusions. GPs have important misconceptions as to the indications for ordering urine cultures and in interpreting the definitions of common UTIs and treating UTIs and asymptomatic bacteriuria. The unnecessary use of antibiotics in patients with asymptomatic bacteriuria is considerable in Spain.

Rev Esp Quimioter 2017;  30 (5): 372-378 [Full-text PDF]

/por

Rev Esp Quimioter 2017, 30(5): 350-354

Influence of initial protocolized treatment with steroids in length of stay and costs of community acquired pneumonia

JOAQUÍN GÓMEZ GÓMEZ, JORGE-LUIS GÓMEZ TORRES, ALICIA HERNÁNDEZ TORRES, JOSÉ ANTONIO GARCÍA CÓRDOBA, MANUEL CANTERAS JORDANA

Objective. The aim of the study was to analyze the impact of steroid treatment in patients with community acquired pneumonia (CAP), both in length of stay and economical cost of admission at a clinical university hospital.
Patients and methods. Prospective study of admitted patients with the diagnosis of CAP, both in Internal Medicine and Infectious diseases department. The study was conducted from January to march 2015; patients receiving steroids from diagnosis to end of antibiotic treatment were classified as group I; otherwise, they were considered in group II. Administration of steroids was done according to the criteria of the responsible. Cost was stablished according to CAP Diagnostic Related Group (DRG).
Results. Prevalence of patients younger than 65 year-old was higher in group I (p<0.05). In bivariate analyses, mean admission time was lower in group I (5.37 vs 8.88 days) (p<0.0005) and also economical cost (2,361 euros vs 3,907 euros) (p<0.0005). In multivariate analysis, factors independently associated to higher cost (>3,520 euros) were COPD (OR=2.602; 95% CI 1.074-6.305) and group II (patients with no steroids) (OR=6.2; p=0,007).
Conclusions. No administration of steroids in patients with CAP was associated, together with COPD, with higher economical cost (evaluated by DRG/length of stay).

Rev Esp Quimioter 2017; 30(5): 350-354 [Texto completo – PDF]

/por

Rev Esp Quimioter 2017, 30(5): 327-333

Infectious complications related to external ventricular shunt. Incidence and risk factors

LUCÍA LÓPEZ-AMOR, LUCÍA VIÑA, LORENA MARTÍN, CLEMENTINA CALLEJA, RAQUEL RODRÍGUEZ-GARCÍA, IVÁN ASTOLA, LORENA FORCELLEDO, LAURA ÁLVAREZ-GARCÍA, CARMEN DÍAZ-GÓMEZ, JAVIER FERNÁNDEZ-DOMÍNGUEZ, FERNANDO VÁZQUEZ, DOLORES ESCUDERO, GRUPO DE INVESTIGACIÓN EN MICROBIOLOGÍA TRASLACIONAL DEL INSTITUTO DE INVESTIGACIÓN SANITARIA DEL PRINCIPADO DE ASTURIAS (ISPA)

Introduction.  Infectious complications related to external ventricular shunt (ICREVS) are a main problem in neurocritical intensive care units (ICU). The aim of the review is to assess the incidence of ICREVS and to analyse factors involved.
Material and methods.  Retrospective analysis, adult polyvalent ICU in a third level reference hospital. Patients carrying external ventricular shunt (DVE) were included. Those patients with central nervous system infection diagnosed prior DVE placement were excluded.
Results. 87 patients were included with 106 DVE. Most common admittance diagnosis was subarachnoid haemorrhage (49.4%). 31 patients with 32 DVE developed an ICREVS. Infection rate is 19.5 per 1000 days of shunt for ICREVS and 14 per 1000 days for ventriculitis. 31.6% of the patients developed ICREVS and 25.3% ventriculitis. Patients who developed ICREVS presented higher shunt manipulations (2.0 ± 0.6 vs. 3.26 ± 1.02, p=0.02), shunt repositioning (0.1 ± 0.1 vs. 0.2 ± 0.1) and ICU and hospital stay (29.8 ± 4.9 vs 49.8 ± 5.2, p<0.01 y 67.4 ± 18.8 vs. 108.9 ± 30.2, p=0.02. Those DVE with ICREVS were placed for longer not only at infection diagnosis but also at removal (12.6 ± 2.1 vs. 18.3 ± 3.6 and 12.6 ± 2.1 vs. 30.4 ± 7.3 days, p<0.01). No difference in mortality was found.
Conclusions. One out of three patients with a DVE develops an infection. The risk factors are the number of manipulations, repositioning and the permanency days. Patients with ICREVS had a longer ICU and hospital average stay without an increase in mortality.

Rev Esp Quimioter 2017; 30(5): 327-333 [pdf]

/por

Rev Esp Quimioter 2017, 30(5): 334-340

Gastrostomy tubes: indications and infectious complications in a tertiary hospital

MARÍA JOSÉ MUÑOZ-DÁVILA, JOSÉ MARÍA XANDRI GRAUPERA, GENOVEVA YAGÜE GUIRAO, CARME SALVADOR GARCÍA, MANUEL SEGOVIA HERNÁNDEZ

Introduction. Gastrostomy tube is the best option for long-term enteral nutrition. Among its limitations, infections represent the most frequent minor complication. Our aim is the knowledge of the number and type of gastrostomy tubes and its main indication in our hospital. In addition, prevalence of infectious complications was studied paying attention to the main etiologic agents and their antibiotic susceptibility.
Methods. Observational retrospective study from January 2010 to July 2015 through the electronic clinical history and the clinical microbiology laboratory software. Identification and antibiotic susceptibility of clinically significant isolates from patients with suspicion of gastrostomy tube infection have been analysed.
Results. Percutaneous endoscopic gastrostomy was performed in 203 patients (70.5%) and surgical gastrostomy in 85 (29.5%). The main reason identified for starting enteral nutrition through gastrostomy tube was malignant neoplasy, above all, lip, oral cavity and pharynx cancer (11.8%) and that from digestive organs (8.7%). Global prevalence of gastrostomy tube infection was 16.6%. The most common bacterial pathogens isolated wereStaphylococcus aureus (21.3%), Pseudomonas aeruginosa (13.1%), and Escherichia coli (9.8%). The percentage of multi resistant isolates was 3.1%.
Conclusions. Gastrostomy tube indications and type, and also, prevalence and microorganisms isolated from culture in infectious complications are similar to those described previously in the literature. The study allows the adaptation of the antibiotic prophylaxis and empirical antibiotic treatment thanks to the knowledge of the etiologic agents and their antibioticsusceptibility.

Rev Esp Quimioter 2017; 30(5): 334-340 [Texto completo – PDF]

/por

Rev Esp Quimioter 2017, 30(5): 368-371

Importance of the forensic autopsy in the diagnosis of septic shock: a case report

AGUSTÍN SIBÓN-OLANO, ENCARNACIÓN SÁNCHEZ-RODRÍGUEZ, MÓNICA PAYÁ, ESTEFANÍA BARRERA-PÉREZ, MANUEL SALGUERO-VILLADIEGO, AMPARO FERNÁNDEZ-RODRÍGUEZ

Septic shock sometimes starts with unspecific symptoms that hamper the clinical diagnosis and, therefore an appropriate treatment. When the septic shock follows a fulminating course with a fatal outcome, the etiological diagnosis has to be conducted post-mortem. Sudden unexpected deaths in children and young adults are frequently the object of medico-legal autopsies. Some sudden unexpected deaths have an infectious origin, which requires further analyses, including microbiology, to establish the cause of death. Here, the case of a fatal septic shock in a 19-month old male infant is presented. After a mild foot injury, an infection by Streptococcus pyogenes progressed to septic shock with a fatal outcome as post-mortem studies demonstrated.

Rev Esp Quimioter 2017; 30(5): 368-371 [Texto completo – PDF]

/por