Neumonía por Pasteurella multocida y Staphylococcus aureus en una paciente sin patología subyacente / Pneumonia by Pasteurella multocida and Staphylococcus aureus in a patient whithout underlying conditions / Pneumonia por Pasteurella multocida e Staphylococcus aureus em uma paciente sem patologia subjacente

Resumen Muchos microorganismos capaces de producir infecciones en el ser humano son de origen zoonótico. Entre éstos está Pasteurella multocida, la cual se encuentra como comensal y/o patógeno oportunista, colonizando el tracto gastrointestinal y respiratorio de gran cantidad de mamíferos y aves. Por otro lado, Staphylococcus aureus es un colonizante de piel y nasofaringe y un patógeno oportunista para seres humanos y animales y su transmisión podría ser bidireccional. Se presenta un caso de neumonía por P. multocida y S. aureus en una mujer sin enfermedad subyacente, que acogía perros y gatos abandonados e ingresó con politraumatismo por caída desde un quinto piso. Ambos microorganismos fueron recuperados en una muestra de aspirado traqueal e identificados por Vitek®2 Compact. La identificación de P. multocida fue confirmada por espectrometría de masas (MALDI-TOF-MS) y presentó sensibilidad a penicilina, cefotaxima, amoxicilina-ácido clavulánico, ciprofloxacina, tetraciclina y trimetoprima-sulfametoxazol. S. aureus era sensible a meticilina sin resistencia acompañante.

Abstract Many microorganisms capable of producing infections in humans are of zoonotic origin. Among them, Pasteurella multocida, is a commensal and/or opportunistic pathogen that colonises the gastrointestinal and the respiratory tract of a great number of mammals and birds. On the other hand, Staphylococcus aureus is a coloniser of skin and nasopharynx and an opportunistic pathogen in humans and animals, whose transmission might be bidirectional. A case of pneumonia by P. multocida and S. aureus was presented in a woman without an underlying condition, who sheltered stray dogs and cats and was admitted with multiple trauma due to a fall from a fifth floor. Both microorganisms were recovered from a tracheal aspirate sample and identified by Vitek®2 Compact. Identification of P. multocida was confirmed by mass spectrometry (MALDI-TOF MS) and was susceptible to penicillin, cefotaxime, amoxicillin-clavulanic acid, ciprofloxacin, tetracycline and trimethoprim-sulfamethoxazole. S. aureus was methicillin-susceptible without accompanying resistance.

Resumo Muitos dos microrganismos capazes de produzir infecções no ser humano têm origem zoonótico. Entre eles está a Pasteurella multocida, que se encontra como comensal e/ou patógeno oportunista, colonizando o trato gastrintestinal e respiratório de grande quantidade de mamíferos e aves. Por outro lado, Staphylococcus aureus é um colonizador de pele e nasofaringe e um patógeno oportunista para seres humanos e animais e sua transmissão poderia ser bidirecional. Apresenta-se um caso de pneumonia por P. multocida e S. aureus em uma mulher, sem doença subjacente, que abrigava cães e gatos abandonados e entrou com múltiplos traumatismos devido à queda desde o quinto andar. Ambos os microrganismos foram obtidos da amostra de aspiração traqueal e identificados por Vitek®2 Compact. A identificação de P. multocida foi validada por espectrometria de massas (MALDI-TOF MS) e apresentou sensibilidade à penicilina, cefotaxima, amoxicilina-ácido clavulânico, ciprofloxacina, tetraciclina e trimetoprim-sulfometoxazol. S. aureus era meticilino sensível sem resistência acompanhante.

Infecciones asociadas a catéteres venosos centrales: Actualización y recomendaciones intersociedades / Central venous catheter related infections. Inter-Societies update and recommendations

Representantes de la Sociedad Argentina de Infectología (SADI) y la Sociedad Argentina de Terapia Intensiva (SATI) se reunieron para trabajar en la elaboración de recomendaciones concretas de diagnóstico, tratamiento y prevención de las infecciones asociadas a catéteres venosos centrales (IAC). La metodología utilizada fue el análisis de la bibliografía publicada en los últimos 10 años complementada con la opinión de expertos y datos locales. En este documento se pretende ofrecer herramientas básicas de optimización de diagnóstico sobre la base de criterios clínicos y microbiológicos, orientar acerca de los esquemas antibióticos empíricos y dirigidos, la posología y la administración de antibióticos en pacientes críticos, y promover las medidas efectivas para reducir el riesgo de IAC. Asimismo, se ofrece un algoritmo de diagnóstico y tratamiento para uso en la actividad asistencial y consideraciones sobre la dosificación de antibióticos. Este trabajo conjunto de infectólogos e intensivistas pone en evidencia la preocupación por el manejo de las IAC y la importancia de velar por la mejora en las prácticas cotidianas. A través de esta recomendación se establecen pautas locales para optimizar el diagnóstico, el tratamiento y la prevención de las IAC con el objeto de disminuir la morbimortalidad, los días de internación, los costos y la resistencia antimicrobiana.

Representatives of the Argentine Society of Infectious Diseases (SADI) and the Argentine Society of Intensive Therapy (SATI) joined together to issue specific recommendations for the diagnosis, treatment, and prevention of intravascular catheter related infections (CRI). The methodology used was the analysis of the literature published in the last 10 years, complemented with the opinion of experts and local data. This document aims to promote effective measures to reduce the risk of CRI and to offer basic tools for diagnosis optimization based on clinical and microbiological criteria, orientation on empirical and targeted antibiotic schemes, posology, and administration of antibiotics in critical patients. It also offers a diagnostic and treatment algorithm for use in the care activity, as well as considerations on the dosage of antibiotics. The joint work of both societies highlights the concern for the management of CRI and the importance of ensuring improvement in daily practices. Through this recommendation, local guidelines are established to optimize the diagnosis, treatment and prevention of CRI in order to reduce morbidity and mortality, days of hospitalization, costs, and antimicrobial resistance.

[Central venous catheter related infections. Inter-Societies update and recommendations]. / Infecciones asociadas a catéteres venosos centrales. Actualización y recomendaciones intersociedades.

Representatives of the Argentine Society of Infectious Diseases (SADI) and the Argentine Society of Intensive Therapy (SATI) joined together to issue specific recommendations for the diagnosis, treatment, and prevention of intravascular catheter related infections (CRI). The methodology used was the analysis of the literature published in the last 10 years, complemented with the opinion of experts and local data. This document aims to promote effective measures to reduce the risk of CRI and to offer basic tools for diagnosis optimization based on clinical and microbiological criteria, orientation on empirical and targeted antibiotic schemes, posology, and administration of antibiotics in critical patients. It also offers a diagnostic and treatment algorithm for use in the care activity, as well as considerations on the dosage of antibiotics. The joint work of both societies highlights the concern for the management of CRI and the importance of ensuring improvement in daily practices. Through this recommendation, local guidelines are established to optimize the diagnosis, treatment and prevention of CRI in order to reduce morbidity and mortality, days of hospitalization, costs, and antimicrobial resistance.

Health-care-associated bloodstream infections at admission to the ICU.

BACKGROUND: Infections occurring among outpatients having recent contact with the health-care system have been recently classified as health-care-associated infections to distinguish them from hospital- and community-acquired infections. Patients with bloodstream infections (BSIs) were studied to assess health-care-associated infections at admission in the ICU. METHODS: This work was a multicenter, prospective, observational study of all adult patients with BSI at ICU admission at 27 Spanish hospitals and one Argentine hospital. Cases of BSI were classified as community-acquired BSI (CAB), health-care-associated BSI (HCAB), or hospital-acquired BSI (HAB), and their characteristics were compared. RESULTS: Of 726 BSIs, 343 (47.2%) were CABs, 252 (34.7%) were HABs, and 131 (18.0%) were HCABs. Potentially antibiotic-resistant pathogens were more frequently isolated in HABs (34.8%) and HCABs (27.6%) than in CABs (10.3%) (P < .001). Logistic regression analysis revealed that HABs (OR, 4.6; 95% CI, 2.9-7.3), HCABs (OR, 3.1; 95% CI, 1.8-5.4), and BSIs of unknown origin (OR, 1.7; 95% CI, 1.0-2.8) were independently associated with the isolation of potentially antibiotic-resistant pathogens. The incidence of inappropriate treatment was significantly higher in HABs (OR, 3.4; 95% CI, 2.1-5.3) and in HCABs (OR, 1.8; 95% CI, 1.0-3.2) than in CABs. CONCLUSIONS: One in five BSIs diagnosed at ICU admission is health-care-associated. The incidence of potentially drug-resistant pathogens in HCABs is more similar to that of HABs, and they should be treated as such until culture data are available.

Pandemic 2009 influenza A in Argentina: a study of 337 patients on mechanical ventilation.

RATIONALE: The rapid spread of the 2009 Influenza A (H1N1) around the world underscores the need for a better knowledge of epidemiology, clinical features, outcomes, and mortality predictors, especially in the most severe presentations. OBJECTIVES: To describe these characteristics in patients with confirmed, probable, and suspected viral pneumonia caused by 2009 influenza A (H1N1) admitted to 35 intensive care units with acute respiratory failure requiring mechanical ventilation in Argentina, between June 3 and September 7. METHODS: Inception-cohort study including 337 consecutive adult patients. Data were collected in a form posted on the Argentinian Society of Intensive Care website. MEASUREMENTS AND MAIN RESULTS: Proportions of confirmed, probable, or suspected cases were 39%, 8%, and 53% and had similar outcomes. APACHE II was 18 +/- 7; age 47 +/- 17 years; 56% were male; and 64% had underlying conditions, with obesity (24%), chronic obstructive respiratory disease (18%), and immunosupression (15%) being the most common. Seven percent were pregnant. On admission, patients had severe hypoxemia (Pa(O(2))/Fi(O(2)) 140 [87-200]), extensive lung radiologic infiltrates (2.87 +/- 1.03 quadrants) and bacterial coinfection, (25%; mostly with Streptococcus pneumoniae). Use of adjuvants such as recruitment maneuvers (40%) and prone positioning (13%), and shock (72%) and acute kidney injury requiring hemodialysis (17%), were frequent. Mortality was 46%, and was similar across all ages. APACHE II, lowest Pa(O(2))/Fi(O(2)), shock, hemodialysis, prone positioning, and S. pneumoniae coinfection independently predicted death. CONCLUSIONS: Patients with 2009 influenza A (H1N1) requiring mechanical ventilation were mostly middle-aged adults, often with comorbidities, and frequently developed severe acute respiratory distress syndrome and multiorgan failure requiring advanced organ support. Case fatality rate was accordingly high.

Usefulness of the "Candida score" for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: a prospective multicenter study.

OBJECTIVE: To assess the usefulness of the "Candida score" (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point. DESIGN: Prospective, cohort, observational study. SETTING: Thirty-six medical-surgical intensive care units of Spain, Argentina, and France. PATIENTS: A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007. MEASUREMENTS AND MAIN RESULTS: Clinical data, surveillance cultures for fungal growth, and serum levels of (1-3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition x1, plus surgery x1, plus multifocal Candida colonization x1, plus severe sepsis x2. A CS >or=3 accurately selected patients at high risk for IC. The colonization index was registered if >or=0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06-3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p 7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.

Incidence and clinical effects of intra-abdominal hypertension in critically ill patients.

OBJECTIVE: The objective of this study was to determine the epidemiology and outcomes of intra-abdominal hypertension in a heterogeneous intensive care unit population. DESIGN: This was a prospective cohort study. SETTING: This study was conducted at a medical-surgical intensive care unit in a university hospital. PATIENTS: Study patients included all those consecutively admitted during 9 months, staying > 24 hrs, and requiring bladder catheterization. MEASUREMENTS AND MAIN RESULTS: On admission, epidemiologic data and risk factors for intra-abdominal hypertension were studied; then, daily maximal and mean intra-abdominal pressures (IAP(max) and IAP(mean)), abdominal perfusion pressure, fluid balances, filtration gradient, and sequential organ failure assessment score, were registered. IAPs were recorded through a bladder catheter every 6 hrs until death, discharge, or along 7 days. Intra-abdominal hypertension was defined as IAP > or = 12 mm Hg. Abdominal compartment syndrome was defined as IAP > or = 20 mm Hg plus > or = 1 new organ failure. Main outcome measure was hospital mortality. Of 83 patients, considering IAP(max), 31% had intra-abdominal hypertension on admission and another 33% developed it after (23% and 31% with IAP(mean)). Main risk factors were mechanical ventilation, acute respiratory distress syndrome, and fluid resuscitation (relative risk, 5.26, 3.19, and 2.50, respectively). Patients with intra-abdominal hypertension were sicker, had higher mortality (53% vs. 27%, p = .02), and consistently showed higher total and renal sequential organ failure assessment score, daily and cumulative fluid balances, and lower filtration gradient. Nonsurvivors had higher IAP(max), IAP(mean), and fluid balances and lower abdominal perfusion pressure. Abdominal compartment syndrome developed in 12%; 20% survived. Logistic regression identified IAP(max) as an independent predictor of mortality (odds ratio, 1.17; 95% confidence interval, 1.05-1.30; p = .003) after adjusting with Acute Physiology and Chronic Health Evaluation II and comorbidities (odds ratio, 1.15; 95% confidence interval, 1.06-1.25; p = .001; and odds ratio, 2.68; 95% confidence interval, 1.27-5.67; p = .013, respectively). Models with IAP(mean) and abdominal perfusion pressure also performed well. Areas under receiver operating characteristic curves were .81 and .83. CONCLUSIONS: Intra-abdominal hypertension, diagnosed either with IAP(max) or IAP(mean), was frequent and showed an independent association with mortality. Intra-abdominal hypertension was significantly associated with more severe organ failures, particularly renal and respiratory, and a prolonged intensive care unit stay.

Infecciones asociadas a catéteres venosos centrales en pacientes críticos / Central venous catheter-related infections in critically ill patients

Objetivo: Determinar la incidencia de las distintas infecciones asociadas a catéteres (IAC): colonización del catéter (CC), bacteriemia asociada a catéter (BAC) e infecciones del sitio de salida (ISS), de acuerdo a las definiciones del CDC. Diseño: Estudio observacional, prospectivo, realizado en una UTI polivalente de 8 camas de un hospital escuela, durante el período de un año. Materiales y métodos: Fueron incluidos todos los pacientes ingresados a UTI desde el 01/01/00 al 01/01/01 que requirieran catéteres venosos centrales (CVC) durante más de 24 hs. Se consideró CC como el crecimiento de ò15 UFC en un recuento semicuantitativo o de ò10 UFC en un recuento cuantitativo de la punta distal del catéter con hemocultivos negativos; BAC al aislamiento del mismo germen (idéntica tipificación y sensibilidad) en la punta del catéter por cultivo semicuantitativo o cuantitativo y en hemocultivos periféricos; e ISS ante la presencia de eritema, induración o purulencia hasta 2 cm del sitio de salida del catéter. Los accesos utilizados fueron yugular, femoral y subclavio...

Estudio propectivo randomizado comparando eficacia y complicaciones de la nutrición enteral por sonda nasogástrica versus sonda postpilórica / A prospective study randomized comparative efficacy and complications of the enteral feeding by nasogastric tube vs. postpiloric tube

Objetivos: evaluar la eficacia y complicacciones en pacientes críticos que recibieron nutrición enteral, comparando la nutrición gástrica y la pospilórica. Diseño: ensayo clínico prospectivo randomizado. Lugar: Unidad de Terapia Intensiva polivalente de un Hospital Universitario, de 8 camas. Pacientes: un total de 43 pacientes críticos que requirieron NE durante más de 48 horas. Material y métodos: se evaluaron las siguientes complicaciones relacionadas a la NE: 1) gastrointestinales: alto residuo gástrico, diarrea, vómitos, distensión abdominal, regurgitación, constipación; y 2) no gastrointestinales: hiperglucemia y neumonía. Se evaluó la eficacia de administración como tasa de kcal administradas/prescriptas. Intervenciones: los pacientes fueron randomizados a recibir nutrición gástrica o nutrición post pilórico. Resultados: fueron incluídos 43 pacientes; 24 correspondieron a nutrición gástrica y 19 a nutrición postpilórica. Ambos grupos fueron igual en edad, sexo, APACHE II, Mc Cabe, TISS y mortalidad predicha. No hubo diferencias en el porcentaje de pacientes en asistencia ventilatoria mecánica, ni en mortalidad. El grupo postpilórico presento mayor día de ventilación mecánica y en estadía en UTI. Se presentaron 81 por ciento de complicaciones gastrointestinales (NG: 84 NPP: 79), todos las variables no fueron significativas...