Positive-pressure needleless connectors did not increase rates of catheter hub colonization respecting the use of neutral-pressure needleless connectors in a prospective randomized trial.

INTRODUCTION: The aim of this study was to compare the colonization rates of central venous catheter (CVC) and arterial catheter (ArtC) hubs fitted with two types of needleless connectors (NCs). METHODS: We designed a prospective randomized study to compare rates of catheter hub colonization of CVC and ArtC hubs fitted with two types of needleless connectors: neutral-pressure NCs (NP-NCs) and positive-pressure NCs (PP-NCs) in critically ill patients. All NCs were replaced every 7 days of use. RESULTS: We obtained 326 cultures from 146 catheters (81 CVC and 65 ArtC) in 70 patients. The total cumulative days of risk were 1250 catheter-days. Global swab cultures were positive in NP-NCs in 29/198 (14.6%) versus 17/128 (13.3%) in PP-NCs during catheter use. We did not observe any cases of CRBSI. CONCLUSIONS: In our experience, the use of PP-NCs did not result in significantly more frequent hub colonization with respect to NP-NCs.

Molecular characterization of OXA-48 carbapenemase-producing Klebsiella pneumoniae strains after a carbapenem resistance increase in Catalonia.

INTRODUCTION: To characterize OXA-48 carbapenemase-producing Klebsiella pneumoniae strains isolated after an increase in carbapenem resistance in Catalonia. METHODOLOGY: K. pneumoniae identification, antimicrobial susceptibility studies, the Modified Hodge Test method, amplification of antimicrobial resistance genes (against ß-lactamases, quinolones and aminoglycosides), molecular typing (by PFGE and MLST), conjugation assays, plasmid characterization (PBRT-PCR and Southern blot), a description of mobile genetic elements and statistical analysis were done. RESULTS: OXA-48 was the only carbapenemase detected, with a prevalence of 1.9%. The blaOXA-48 gene was located in an IncL conjugative plasmid of 62kb and integrated into the transposons Tn1999.2 (91.7%) or Tn1999.1. Five PFGE profiles (A to E) were found, which exactly matched the MLST: ST101, ST17, ST1233, ST14 and ST405, respectively. ST1233 is described here for the first time. K. pneumoniae OXA-48-producing strains were also CTX-M-15 carriers, some producing OXA-1 and TEM-1 penicillinases. The acquired qnrB66 and qnrB1 and aac(3')-IIa, aac(6')-Ib genes were also identified. CONCLUSION: The K. pneumoniae ST405 clone has played an important role in the growing prevalence of OXA-48 in Catalonia. All clones described preserved the blaOXA-48 genetic environment and mobile genetic elements (Tn1999). Notably, the three strains with minor sequence types in this study are not multiresistant strains. These strains are expanding in elderly patients (average age of 76 years) with serious underlying diseases, mainly women (61.2%).

Serotypes and Clonal Diversity of Streptococcus pneumoniae Causing Invasive Disease in the Era of PCV13 in Catalonia, Spain.

The aim of this study was to study the serotypes and clonal diversity of pneumococci causing invasive pneumococcal disease in Catalonia, Spain, in the era of 13-valent pneumococcal conjugate vaccine (PCV13). In our region, this vaccine is only available in the private market and it is estimated a PCV13 vaccine coverage around 55% in children. A total of 1551 pneumococcal invasive isolates received between 2010 and 2013 in the Molecular Microbiology Department at Hospital Sant Joan de Déu, Barcelona, were included. Fifty-two serotypes and 249 clonal types-defined by MLST-were identified. The most common serotypes were serotype 1 (n = 182; 11.7%), 3 (n = 145; 9.3%), 19A (n = 137; 8.8%) and 7F (n = 122; 7.9%). Serotype 14 was the third most frequent serotype in children < 2 years (15 of 159 isolates). PCV7 serotypes maintained their proportion along the period of study, 16.6% in 2010 to 13.4% in 2013, whereas there was a significant proportional decrease in PCV13 serotypes, 65.3% in 2010 to 48.9% in 2013 (p<0.01). This decrease was mainly attributable to serotypes 19A and 7F. Serotype 12F achieved the third position in 2013 (n = 22, 6.4%). The most frequent clonal types found were ST306 (n = 154, 9.9%), ST191 (n = 111, 7.2%), ST989 (n = 85, 5.5%) and ST180 (n = 80, 5.2%). Despite their decrease, PCV13 serotypes continue to be a major cause of disease in Spain. These results emphasize the need for complete PCV13 vaccination.

Microbiological study of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and the usefulness of analytical and clinical parameters in its identification (VIRAE study).

PURPOSE: Respiratory infection is the most common cause for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The aim of this work was to study the etiology of the respiratory infection in order to assess the usefulness of the clinical and analytical parameters used for COPD identification. PATIENTS AND METHODS: We included 132 patients over a period of 2 years. The etiology of the respiratory infection was studied by conventional sputum, paired serology tests for atypical bacteria, and viral diagnostic techniques (immunochromatography, immunofluorescence, cell culture, and molecular biology techniques). We grouped the patients into four groups based on the pathogens isolated (bacterial versus. viral, known etiology versus unknown etiology) and compared the groups. RESULTS: A pathogen was identified in 48 patients. The pathogen was identified through sputum culture in 34 patients, seroconversion in three patients, and a positive result from viral techniques in 14 patients. No significant differences in identifying etiology were observed in the clinical and analytical parameters within the different groups. The most cost-effective tests were the sputum test and the polymerase chain reaction. CONCLUSION: Based on our experience, clinical and analytical parameters are not useful for the etiological identification of COPD exacerbations. Diagnosing COPD exacerbation is difficult, with the conventional sputum test for bacterial etiology and molecular biology techniques for viral etiology providing the most profitability. Further studies are necessary to identify respiratory syndromes or analytical parameters that can be used to identify the etiology of new AE-COPD cases without the laborious diagnostic techniques.

[Peripheral venous catheter-related bacteremia in a general hospital]. / Características de la bacteriemia relacionada con catéter venoso periférico en un hospital general.

INTRODUCTION: Catheter sepsis is a constant and serious problem in our hospitals for the cost it generates, both in terms of morbidity and economics. It's becoming more frequent also in peripherally inserted catheters. Our study aims to know the importance and characteristics of peripheral venous catheter bacteremia in a general hospital. MATERIAL AND METHODS: Prospective and comparative analysis of all episodes of central and peripheral venous catheter-related bacteraemia, in 2009. RESULTS: Twenty-eight episodes of catheter-related bacteraemia in a total of 25 patients. Sixteen episodes originated in central catheter (57.2%), 11 in peripheral (39.3%) and 1 in peripherally inserted central catheter (3.5%). Two cases of exitus directly related to the peripheral catheter infection. ETIOLOGY: 13 episodes of S. aureus (3 MRSA), including 8 in peripheral catheter (8/13, 61.5%), 12 episodes of plasma coagulase negative staphylococcus, including 2 in peripheral catheter (2/12, 16.6%). CONCLUSIONS: Peripheral catheter-related bacteraemia is an emerging health problem with important clinical and prognostic connotations for patients. It is necessary continuous training on correct handling measures to prevent intravascular catheters infections including peripheral catheters in every hospital ward.

Serotypes and clones causing invasive pneumococcal disease before the use of new conjugate vaccines in Catalonia, Spain.

OBJECTIVES: The objective of this study was to learn the serotype distribution and clonal composition of pneumococci causing invasive pneumococcal disease (IPD) in children and adults in Spain before the introduction of new 10-valent (PCV10) and 13-valent (PCV13) conjugate vaccines. METHODS: This is a 1-year prospective study including all patients with culture-proved IPD admitted to 30 medical centers in Catalonia, Spain, during the year 2009. RESULTS: A total of 614 episodes of IPD occurred in 612 patients. The rates of IPD were highest in children aged <24 months and adults >64 years (64.5 and 44.7 per 100,000 population). The burden of disease was mainly due to pneumonia in all age ranges. 609 of 614 strains were serotyped and 47 different serotypes were found. Among the 609 IPD cases with known serotype, 12.2% were caused by PCV7 serotypes, 51% by PCV10 serotypes, and 71.7% by PCV13 serotypes. 608 of 614 isolates were characterized by MLST. The main clonal types detected were ST306, CC191 and CC230. CONCLUSIONS: PCV13 conjugate vaccine offers good coverage against IPD in Catalonia, Spain. However, the high genetic diversity of pneumococci highlights the importance of molecular surveillance systems for monitoring IPD during the vaccination period. SUMMARY: This study shows that 13-valent conjugate vaccine offers good coverage against invasive pneumococcal disease in children and adults in Spain. However, the high genetic diversity of pneumococci highlights the importance of molecular surveillance systems for monitoring IPD during the vaccination period.

Efficacy of three different valve systems of needle-free closed connectors in avoiding access of microorganisms to endovascular catheters after incorrect handling.

OBJECTIVE: Disinfectable needle-free closed connectors were designed to avoid needle-stick injuries and to be easily disinfected before handling. Workloads or lack of knowledge, however, could impede the correct handling of these devices, allowing endoluminal catheter colonization. The aim of our study was to assess the barrier effect of different disinfectable needle-free closed connectors during correct and incorrect handling using an experimental model. DESIGN: We used a model consisting of a blood culture bottle with a peripheral venous catheter inserted under sterile conditions. Three different disinfectable needle-free closed connectors with different valve designs (microClave, Bionector, and Smartsite plus) were used to close the catheters. The external surfaces of the disinfectable needle-free closed connectors were contaminated with different concentrations of a Staphylococcus epidermidis culture broth. After contamination, 10 units of each connector and each concentration were assigned to the correct handling group (cleaned with 70% ethylic alcohol before handling) and the same number to the incorrect handling group (handled without disinfection) with a total of 180 bottles. RESULTS: Increases in concentrations of external contamination and incorrect handling of the connectors resulted in an increase in connectors' permeability to the pass of microorganisms to the endoluminal way. MicroClave proved the best barrier in the experimental conditions described. CONCLUSION: The barrier effect of disinfectable needle-free closed connectors is adversely affected by incorrect handling, the quantity of external valve colonization, and the valve design.

Differences in the etiology of community-acquired pneumonia according to site of care: a population-based study.

BACKGROUND: A few population-based studies assessing the etiology of community-acquired pneumonia in both hospitalized and ambulatory patients, with special emphasis on the etiologic role of viral infections, have been reported. The purpose of this study was to assess microbiological differences according to initial site of care in patients with community-acquired pneumonia. METHODS: We studied 496 patients > 14 years of age collected from the study samples of three population-based studies carried out in the same geographical area ("Maresme" region in the Mediterranean coast in Barcelona, Spain) with the same methodology over an 8-year period (1987-1995). RESULTS: Fifty-six percent of patients were hospitalized and 44% were treated at home. Of the 474 patients with etiological evaluation, 195 patients had an identifiable etiology (overall diagnostic yield 41%). Streptococcus pneumoniae was the most common causative organism. Viral infection was diagnosed in 26.5% of hospitalized patients vs. 13.2% of ambulatory patients (P=0.03). Twenty-five percent of the 68 patients with documented etiology treated at home had Chlamydia pneumoniae infection compared with 14.3% of those treated in the hospital. Ten percent of hospitalized patients had pneumonia caused by two pathogens compared with 9.7% of ambulatory patients. The association of viruses and bacteria was the most frequent cause of dual infection (79% inpatients, 67% outpatients). CONCLUSIONS: This study has provided information on etiology of community-acquired pneumonia in hospitalized patients and in patients treated at home. A considerable proportion of patients had viral pneumonia, frequently requiring hospital admission for inpatient care.

Contribution of C-reactive protein to the diagnosis and assessment of severity of community-acquired pneumonia.

STUDY OBJECTIVE: To assess the usefulness of serum C-reactive protein (CRP) in the diagnosis and treatment approach of patients with community-acquired pneumonia (CAP). DESIGN: Population-based case-control study. SETTING: A mixed residential-industrial urban area of 74,368 adult inhabitants in the Maresme region (Barcelona, Spain). PATIENTS: From December 1993 to November 1995, all subjects who were > 14 years of age, were living in the area, and had received a diagnosis of CAP, which had been confirmed by chest radiographs and compatible clinical outcome, were registered. Patients from residential care facilities were excluded. Serum samples were assayed for CRP in the acute phase of the disease. Data from 201 patients with CAP were compared with 84 healthy control subjects matched by age, sex, and municipality, as well as with 25 patients with initially suspected pneumonia that was not confirmed at follow-up. Median CRP levels were 110.7, 1.9, and 31.9 mg/L, respectively. The thresholds of the test for discriminating among these three groups of subjects were 11.0 and 33.15 mg/L. RESULTS: Eighty-nine patients (44.8%) had an identifiable etiology. The most common pathogens were Streptococcus pneumoniae, viruses, and Chlamydia pneumoniae, followed by Mycoplasma pneumoniae, Legionella pneumophila, and Coxiella burnetii. There were statistically significant differences in the median CRP levels in pneumococcal (166.0 mg/L) and L pneumophila (178.0 mg/L) etiologies compared to other causative pathogens. Lower levels of CRP were found in pneumonia caused by viruses and C burnetii as well as in negative microbiological findings. The median CRP levels in hospitalized patients were significantly higher than in outpatients (132.0 vs 76.9 mg/L, respectively; p < 0.001). Considering a cut point of 106 mg/L in men and 110 mg/L in women for deciding about the appropriateness of inpatient care, CRP levels showed a sensitivity of 80.51% and a specificity of 80.72%. CONCLUSIONS: Serum CRP level is a useful marker for establishing the diagnosis of CAP in adult patients with lower respiratory tract infections. High CRP values are especially high in patients with pneumonias caused by S pneumoniae or L pneumophila. Moreover, high CRP values are suggestive of severity, which may be of value in deciding about the appropriateness of inpatient care.

Resistance to the migration of microorganisms of a needle-free disinfectable connector.

The aim of this study was to assess the efficacy of a disinfectable needle-free connector in reducing the pass of micro-organisms to the lumen of the catheter. A prospective, controlled, experimental trial was performed in which a laboratory model simulated the insertion of a peripheral venous catheter. Catheters inserted in sterile conditions in a hemoculture bottle were closed with the disinfectable needle-free connector (study group) or with a cap (control group). After 9 days of contamination and manipulation of the connector and cap external surfaces, 100% of bottles in the control group were contaminated whereas 60% remained sterile in the study group. The disinfectable needle-free connector showed more resistance to the pass of microorganisms than the conventional cap according to our experimental model.

[Imported hookworm infection in African immigrants in Spain: study of 285 patients]. / Uncinariasis importada por inmigrantes africanos: estudio de 285 casos.

BACKGROUND AND OBJECTIVE: Hookworm infection is a worldwide intestinal parasitic disease affecting more than one billion people. It represents an important public health problem in rural areas of developing countries. In our environment, it is generally considered an imported disease due to the immigration process. PATIENTS AND METHOD: Retrospective observational study of African immigrants diagnosed with hookworm infection at the Immigration and Tropical Medicine Unit of the Hospital of Mataró over the period 1984-1999. RESULTS: We identified 285 patients, mainly young males, from Gambia or Senegal, with a precarious job who had arrived in Spain 3 years earlier or less. Abdominal pain was the commonest reason for consultation (28.8%) cases. Non digestive symptoms were 35.6% and 4.6% remained assymptomatic. 60% had a concomitant infectious disease. Laboratory tests showed iron-deficiency anemia in 28.4% and eosinophilia in 52.3%. 70% of patients did not come to visit after treatment. CONCLUSIONS: Microbiologic stool examination is recommended as part of the health assessment of immigrants from countries where hookworm infection is highly prevalent, even in the absence of abdominal symptoms or abnormalities of the red and white blood series.

[Imported diseases in African immigrants in Spain: study of 1,321 patients]. / Enfermedades importadas en inmigrantes Africanos: estudio de 1.321 pacientes.

BACKGROUND: Immigrants can carry diseases characteristic from their countries of origin. These are known as imported diseases (ID) and can be classified into tropical diseases (TD) or cosmopolitan diseases (CD). The aim of this study was to analyse the ID in African immigrants and evaluate their repercussion in the Spanish Public Health. PATIENTS AND METHOD: Observational study, retrospective protocol, carried from 1984 to 1994 in African immigrants seen in a reference Hospital. Not infectious chronic ID were excluded. The repercussion in public health was divided in 3 categories according to transmission risk to the host population: a) ID without current risk; b) ID with potential risk and, c) ID of risk. RESULTS: 1,321 African immigrants were considered. Most of them were from Sub-Saharan Africa. The most frequent TD were helminthiases and among CD, tuberculosis, sexually transmitted diseases and parasitoses. ID without transmission risk were 26.7% (2.4% CD and 24.3% TD), ID with potential risk 35.2% (33.6% CD and 1.6% TD) and ID with risk 38% (all CD). CONCLUSIONS: The CD and their association with poverty suppose a higher risk of transmission to the host country population. Global policies of helping social and economic insertion of immigrant populations, combined with international health collaboration, will rebound positively in the general population's health.