Nosocomial candidemia: new challenges of an emergent problem 

J. GÓMEZ, E. GARCÍA-VAZQUEZ, A. HERNÁNDEZ, C. ESPINOSA, J. RUIZ GÓMEZ   

 

Candida spp. are currently one of the most common causes of bloodstream infections in hospitals. Over the last two decades there has been a shift towards a greater involvement of non-Candida albicans as the cause of candidemia. Several of these non-albicans spp. (e.g., C. glabrata and C.krusei) exhibit resistance to traditional triazole antifungals (fluconazole), and cross-resistance with newer triazoles (voriconazole), focusing attention on the first-line use of antifungals such as the echinocandins, which possess improved activity against fluconazole-resistant strains. Early and adequate empirical treatment as well as early removing of the central catheters are the main factors related to mortality; thus it is necessary to implement guidelines of empirical treatment (including these aspects) in patients with risk factors and possible candidemia. Recent treatment guidelines from the Infectious Diseases Society of America (IDSA) recommend an echinocandin as primary therapy for non neutropenic or neutropenic patients with moderately severe to severe candidiasis and for patients at risk for infection with a triazole-resistant strain; the increasing MIC of echinocandins in case of C. parapsilosisis also an emerging concern. Clinicians should remain vigilant to prescribe early empiric treatment of patients at risk of having candidemia.   

 
Rev Esp Quimioter 2010:23(4):158-168 [pdf]

Prophylaxis and treatment of invasive fungal infection in neutropenic patients 

C. VALLEJO, M. ROVIRA   

 

Prophylaxis and treatment constitute the basis for reducing the mortality due to IFI. Prophylaxis is currently the standard practice in most hospitals and is recommended by the principal guidelines. Fluconazole has proved to be useful to prevent and reduce the mortality due to yeast IFI in several contexts. Although its use has led to the emergence of some resistant strains of Candida, it has not been a generalized problem and the number of lives saved has been worth it. But its major disadvantage is the lack of impact on IFI by molds. So, in patients at high risk for IFI due to filamentous fungi, it is necessary the employ of extended spectrum drugs. For the empirical and preemptive approach, it is necessary to have in mind which fungi have to be covered and  the spectrum of the available antifungal agents. For the treatment of established infection by Candida spp., before the identification of species, we must consider different host (like the use or not of prophylactic fluconazole) and clinical factors (like the evidence or not of diseminated infection or severe sepsis). Primary combination of antifungal agents for the treatment of invasive aspergillosis has to be considered in cases of central nervous system disease, respiratory failure, serious sepsis,  and extensive or cavitated pulmonary lesions.    

 
Rev Esp Quimioter 2010:23(4):177-183 [pdf]

Significance of lower respiratory tract cultures yielding  Aspergillus spp. growth in a hospital without  transplant patients   

P. LUCENA, J. BARBERÁN, G. EROLES, J. J. GRANIZO, M. J. GIMÉNEZ, N. MIR, L. AGUILAR, J. PRIETO   

 

Introduction: Isolation of Aspergillus spp. in non-neutropenic, non-transplant patients with chronic obstructive pulmonary disease (COPD) usually treated with corticosteroids is not easily interpretable. A retrospective review of clinical records corresponding to cultures (respiratory samples) yielding Aspergillusspp. in non- transplant patients was carried out.

Methods: Patients were assigned to four categories: colonization, possible, probable or definitive aspergillosis. A logistic regression model (step–wise procedure) was performed using as dependent variable mortality, and as independent variables those showing differences (p≤0.1) in the bivariant analysis.

Results:Sixty-nine patients were identified. Most were elderly (68.1% ≥65 years), male (73.9%), presented comorbidities(84.1% Charlson index ≥3), COPD (76.8%), were receiving high corticosteroid doses (66.7%), and had previously received antibiotics (94.2%). Forty-five cases were colonizations, 4 possible, 15 probable and 5 definitive aspergillosis. A. fumigatus was isolated in 75.4% patients:  66.7% colonized, 75% possible,93.3% probable and 100% definitive aspergillosis. Colonized patients were older (71.9 ± 11.9 vs. 65.1 ± 9.2 years; p= 0.018) and presented higher (p=0.034) comorbidity index than patients with aspergillosis. Mortality was 31.1% in colonized vs. 62.5% in aspergillosis (p=0.012).

Conclusion: The isolation of A. fumigatus was associated with an increased probability of aspergillosis, with statistical association in the multivariate analysis between mortality and variables related to chemotherapy (no antifungal treatment), disease (diagnostic category) and immunity (leukocytosis).    

 
Rev Esp Quimioter 2010:23(4):190-195 [pdf]

Impact of the consumption of ophthalmic topical antibiotics   

S. GARCÍA, P. MORI, A. LÓPEZ, L. ALOU, D. MARTINEZ, C. RAMOS, M. L. GÓMEZ-LUS    

 

Introduction. The aim of the study was to value the impact of the consumption of the topical antibiotics used in ophthalmology and to lay the foundations for their prudent use.

Material and methods. A descriptive study about antibiotic use in Spain between 1st January 2004 and 31th December 2008 was carried out. Drugs used in the study had to follow the next criteria: topical administration and ophthalmic antibiotics only or in association. Data of the number of vials and nosocomial consumption were provided by Intercontinental Marketing Services (IMS) and  Health National System, respectively.

Results. Nosocomial and community ophthalmologic antiinfectives in 2008 mean a cost of 4.9 and 24.4 millions of euros, respectively increasing a 5.5% respect to the previous year. Six millions of vials were used, 65% were antibiotics alone and 35% antibiotics in association. The most used ophthalmic antibiotics in monoterapy were the aminoglycosides(tobramycin and gentamicin), followed by the quinolones while the most used ophthalmic antibiotic in association were gramicidine plus neomycine plus polimixin B.

Conclusions.The ophthalmic antiinfectives market, alone and in association, used in the nosocomial and community context means 30 millions of euros and shows an increase about 6%. Strict measures in the antibiotic use are not taken incount in the context of the ophthalmic topical antibiotics.    

 
Rev Esp Quimioter 2010:23(4):201-205 [pdf]

Proton pump inhibitors and infection risk 

E. PALENCIA-HERREJÓN, B. SÁNCHEZ, I. ESCOBAR, M. L. GÓMEZ-LUS   

 

Gastric antisecretory drugs, especially proton pump inhibitors, are among the most used drugs both in ambulatory and hospital settings, and prescription does not always follows approved indications. Experimental data suggest that gastric acid inhibition and the effects of proton pump inhibitors on the immune system can promote the development of infections. In recent years a number of observational studies have found an independent association between the use of proton pump inhibitors and an increased risk of gastrointestinal infections, including those caused by Clostridium difficile, and community and nosocomial pneumonia. This review discusses the current evidence, raises the potential pathogenic mechanisms involved and makes recommendations for current clinical practice and future research.    

 
Rev Esp Quimioter 2011:24(1):4-12 [pdf]