Effectiveness and Safety of Postoperative Hospital at Home for Surgical Patients: A Cohort Study.

OBJECTIVE: To determine the feasibility and effectiveness of a Hospital at Home (HaH) enabled early transfer pathways for surgical patients. BACKGROUND: HaH serves as a safe alternative to traditional hospitalization by providing acute care to patients in their homes through a comprehensive range of hospital-level interventions. To our knowledge, no studies have been published to date reporting a large cohort of early home-transferred patients after surgery through a HaH unit. METHODS: Cohort study enrolling every patient admitted to the HaH unit of a tertiary hospital who underwent any of 6 surgeries with a predefined early transfer pathway and fitting both general and surgery inclusion criteria (clinical and hemodynamic stability, uncomplicated surgery, presence of a caregiver, among others) from November 2021 to May 2023. Protocols were developed for each pathway between surgical services and HaH to deliver the usual postoperative care in the home setting. Discharge was decided according to protocol. An urgent escalation pathway was also established. RESULTS: During the study period, 325 patients were included: 141 were bariatric surgeries, 85 kidney transplants, 45 thoracic surgeries, 37 cystectomies, 10 appendicectomies, and 7 ventral hernia repairs. The overall escalation of care during HaH occurred in 7.3% of patients and 30-day readmissions in 7%. Most adverse events were managed at home and the overall mortality was zero. The total mean length of stay was 8 days (interquartile range 2-14), and patients with HaH were transferred home 3 days (interquartile range 1-6) earlier than the usual pathway; a total of 1551 bed-days were saved. CONCLUSIONS: The implementation of early home transfer pathways for surgical patients through HaH is feasible and effective, with favorable safety outcomes.

Aspergillosis by cryptic Aspergillus species: A case series and review of the literature

Background:The cryptic Aspegillus species are rare, these microorganisms are usually more resistant to common antifungal therapies. Therefore, a correct identification is important when evaluating the impact of such species in aspergillosis.Aims:We aimed to describe the frequency, clinical and microbiological characteristics, and the outcomes of those cases of aspergillosis caused by cryptic species in a tertiary hospital.Methods:We retrospectively identified all microbiologically documented cases of aspergillosis between January 2013 and December 2018. Definitive species identification of clinically significant isolates was achieved via sequencing methods. The polymerase chain reaction (PCR) products were sequenced, and the results obtained were compared to sequences deposited in GenBank. Antifungal susceptibility testing was performed using the Sensititre® YeastOne® panel.Results:A total of 679 Aspergillus isolates were recovered from 489 patients, of which 109 were clinically relevant. Ten (9.2%) isolates were identified as cryptic species: Aspergillus arcoverdensis (2), Aspergillus lentulus (2), Aspergillus ellipticus (2), Aspergillus alliaceus (1), Aspergillus nomius (1), Aspergillus tubingensis (1) and Aspergillus montevidensis (1). Most patients already suffered some type of immunosuppression. Half of these patients had required intensive care before the infection showed up, and most of them had a pulmonary infection. Mortality at the 100-day follow-up was 40%. Antifungal susceptibility testing was performed on three of the isolates (A. arcoverdensis, A. tubingensis and A. nomius), which showed high minimum inhibitory concentrations (MIC) for azoles and amphotericin B.Conclusions:The frequency of cryptic species in our centre was 9.2%. Most patients had some degree of immunosuppression, and the mortality rate was 40%. (AU)

Antecedentes:Las especies crípticas dentro del género Aspergillus son poco habituales, pero suelen mostrar una mayor resistencia al tratamiento antifúngico convencional. Por tanto, una correcta identificación de la especie es necesaria para evaluar el impacto de estas especies crípticas en el desarrollo de la aspergilosis.Objetivos:El objetivo de este estudio fue describir las características clínicas, epidemiológicas y microbiológicas, así como la evolución clínica, de los casos de aspergilosis por especies crípticas en un hospital de tercer nivel.Métodos:Se analizaron de forma retrospectiva todos los casos documentados de aspergilosis con identificación microbiológica entre enero de 2013 y diciembre de 2018. La identificación definitiva de los aislamientos clínicos se realizó mediante métodos de secuenciación. Los productos de amplificación obtenidos por la reacción en cadena de la polimerasa (PCR) fueron secuenciados, y los resultados se analizaron utilizando la base de datos del GenBank. Para el análisis de susceptibilidad a los antifúngicos de los aislamientos identificados se utilizó el panel Sensititre® YeastOne®.Resultados:Se identificaron un total de 679 aislamientos de Aspergillus de 489 pacientes, de los cuales un total de 109 eran clínicamente relevantes. Diez (9,2%) de los aislamientos correspondían a especies crípticas: Aspergillus arcoverdensis (2), Aspergillus lentulus (2), Aspergillus ellipticus (2), Aspergillus alliaceus (1), Aspergillus nomius (1), Aspergillus tubingensis (1) y Aspergillus montevidensis (1). La mayoría de los pacientes tenían algún tipo de inmunosupresión previa. La mitad de estos pacientes habían requerido de cuidados intensivos antes de la infección, y la mayoría sufría una infección pulmonar. La mortalidad a los 100 días de seguimiento fue del 40%. (AU)

Primary immunodeficiency and chronic mucocutaneous candidiasis: pathophysiological, diagnostic, and therapeutic approaches

Chronic mucocutaneous candidiasis (CMC) is characterized by a chronic or recurrent non-invasive infection, mainly due to Candida albicans, in skin, nails, and mucous membranes, associated in some cases with autoimmune manifestations. The key immune defect is a disruption of the action of cytokine IL-17, whose most common genetic etiology is STAT1 gene gain-of-function (GOF) mutations. The initial appropriate treatment for fungal infections is with azoles. However, the frequent occurrence of drug resistance is the main limitation. Therefore, identification of the underlying inborn error if immunity in CMC may allow to widen therapeutic options aimed at restoring immunological function. Type I and II Janus kinase-inhibitors have been shown to control CMC in cases associated with STAT1 GOF. In this review, we delve into the pathogenesis of CMC and the underlying immune mechanisms. We describe the reported genetic defects in which CMC is the main manifestation. Diagnostic and therapeutic approaches for these patients are also offered

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Neck infection after allogenic hematopoietic progenitors transplantation / Infección de cuello tras trasplante alogénico de progenitores hematopoyéticos

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Antibiotic selection in the treatment of acute invasive infections by Pseudomonas aeruginosa

Pseudomonas aeruginosa is characterized by an important intrinsic resistance to antibiotics and it possess an extraordinary ability to develop resistance to nearly all available antimicrobials through selection of mutations. We review some of the pharmacodynamic principles of antibiotics predicting efficacy, clinical experience with monotherapy and combination therapy, and principles for antibiotic treatment for empirical and directed treatment of P. aeruginosa invasive infections

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Prophylaxis of mould infections

Invasive fungal infection continues to be an important cause of morbidity and mortality in haematological patients. Antifungal prophylaxis in these patients has remarkably increased survival since its INTRODUCTION: In recent years, new antifungals have been on the rise, being more effective and having less toxicity than previous ones. Nonetheless, the number of patients at risk of fungal infection has also been increasing due to the continuous appearance of new immunosuppressive treatments. As a result of such, we face a changing situation that requires constant updating

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Top-ten papers in fungal infection / Los mejores artículos sobre infección fúngica

We have clustered the published articles in fungal infection between 2016 and 2017 in four categories. First, the emergence of Candida auris as a nosocomial pathogen associated to high antifungal resistance and high mortality. Second, the growing importance of fungal infections associated to the use of biologic therapies. Third, the approval of isavuconazole for the treatment of filamentous fungi and dymorphic mycoses with positive results and less side effects. And finally, a mix of other important news regarding empiric therapy, fluconazole toxicity and difficult-to-treat fungal infections

Hemos agrupado los artículos publicados sobre infección fúngica entre 2016 y 2017 en cuatro categorías. Primero, la emergencia de Candida auris como un patógeno nosocomial asociado a alta resistencia a antifúngicos y alta mortalidad. Segundo, la creciente importancia de las infecciones fúngicas asociadas al uso de terapias biológicas. Tercero, la aprobación de isavuconazol para el tratamiento de los hongos filamentosos y las micosis por hongos dimórficos con buenos resultados y menos efectos adversos. Y por último, una combinación de otras noticias importantes en cuanto a terapia empírica, toxicidad del fluconazol e infecciones fúngicas difíciles de tratar

Características clínicas y evolución de los pacientes diagnosticados de mucormicosis en un hospital de tercer nivel (2012-2016) / Clinical features and outcome in patients with mucormycosis in a tertiary hospital (2012-2016)

Antecedentes: La descripción antiguamente más frecuente de la mucormicosis era la afectación nasosinusal en pacientes con cetoacidosis diabética. Sin embargo, en los últimos años han surgido nuevos grupos de pacientes con riesgo de mucormicosis. Objetivos y métodos: Se realizó un análisis retrospectivo de las características, tratamiento y evolución de los pacientes con mucormicosis en nuestro hospital (años 2012-2016). Resultados: De los 12 pacientes del estudio, siete padecían alguna enfermedad hematológica como factor predisponente, la mayoría (6 pacientes) por trasplante de progenitores hematopoyéticos. Solamente un paciente estaba en cetoacidosis diabética. Siete pacientes del total estaban recibiendo antifúngicos al inicio de los síntomas, y 9 pacientes los habían recibido los tres meses previos. La afectación fue rinosinusal (16,6%), pulmonar localizada (33,3%), musculoesquelética (25%) y diseminada (25%). En 8 pacientes se realizó desbridamiento quirúrgico. Seis pacientes recibieron tratamiento combinado con anfotericina B y posaconazol (mortalidad de grupo 16%), y 4 pacientes fueron tratados con anfotericina B en monoterapia (mortalidad 50%), con una mortalidad global del 41%. La mortalidad de los pacientes con afectación pulmonar fue del 71%, y en el caso de enfermedad diseminada del 100%. Ningún paciente con afectación únicamente musculoesquelética falleció. Conclusiones: La mucormicosis sigue teniendo una elevada mortalidad, especialmente las formas pulmonares. Las formas musculoesqueléticas tuvieron mejor pronóstico. El grupo de riesgo principal fue el de los pacientes con trasplante de médula ósea. El tratamiento combinado obtuvo mejores resultados que la monoterapia, aunque se necesita más experiencia para definir el tratamiento más adecuado

Background: The most common presentation of mucormycosis in the past was the nasosinusal involvement in patients with diabetic ketoacidosis. However, in the last few years, new groups of patients with risk of mucormycosis have emerged. Aims and methods: Retrospective analysis of the characteristics, treatment and evolution of patients with mucormycosis in a tertiary hospital in the years 2012-2016. Results: Of the 12 patients included in the study, 7 had a haematological disease as a predisposing factor, most of them (6 patients) related to transplantation of haematopoietic progenitors. Only one patient had diabetic ketoacidosis. Seven out of the twelve patients were receiving an antifungal treatment at the onset of symptoms, and 9 patients had received them three months before. The clinical presentation was rhinosinusal (16.6%), localised lung disease (33.3%), and musculoskeletal (25%) and disseminated disease (25%). Surgical debridement was performed on 8 patients. Combination therapy with amphotericin B and posaconazole was received by 6 patients (16% mortality), and 4 patients were treated with amphotericin B alone (50% mortality), with an overall mortality of 41%. The mortality of patients with pulmonary involvement was 71%, increasing to 100% in the case of disseminated disease. None of the patients with only musculoskeletal involvement died. Conclusions: Mucormycosis has a high mortality rate, especially the pulmonary forms. Musculoskeletal involvement had a better prognosis. The main group at risk was that of patients with haematopoietic stem cell transplantation. Combination therapy had better results than monotherapy, although more experience is needed to define the most appropriate treatment

Time-to-positivity, type of culture media and oxidase test performed on positive blood culture vials to predict Pseudomonas aeruginosa in patients with Gram-negative bacilli bacteraemia / Tiempo de positividad, tipo de medio de cultivo y prueba de oxidasa realizada en viales de hemocultivo positivos para predecir Pseudomonas aeruginosa en pacientes con bacteriemia por bacilos gramnegativos

Introduction. The aim of this study was to determine the usefulness of oxidase test and time-to-positivity (TTP) in aerobic and anaerobic blood culture vials to detect the presence of Pseudomonas aeruginosa in patients with Gram-negative bacilli (GNB) bacteraemia. Material and methods. TTP was recorded for each aerobic and anaerobic blood culture vial of monomicrobial bacteraemia due to GNB. Oxidase test was performed in a pellet of the centrifuged content of the positive blood culture. An algorithm was developed in order to perform the oxidase test efficiently taking into account TTP and type of vial. Results. A total of 341 episodes of GNB bacteraemia were analysed. Sensitivity, specificity, positive predictive value and negative predictive value of the oxidase test performed on positive vials with GNB to predict P. aeruginosa were 95%, 99%, 91%, and 99%, respectively. When growth was first or exclusively detected in anaerobic vials, P. aeruginosa was never identified hence the performance of the oxidase test could be avoided. When growth was only or first detected in aerobic vials, a TTP≥8h predicted P. aeruginosa in 37% or cases (63 of 169), therefore oxidase test is highly recommended. Conclusions. Oxidase test performed onto positive blood culture vials previously selected by TTP and type of vials is an easy and inexpensive way to predict P. aeruginosa. In most cases, this can lead to optimization of treatment in less than 24 hours (AU)

Introducción. El objetivo del estudio fue determinar la utilidad de la prueba de oxidasa y del tiempo de positividad del hemocultivo (TPH) para detectar la presencia de Pseudomonas aeruginosa en pacientes con bacteriemia por bacilos gramnegativos (BGN). Material y métodos. Se registró el TPH de cada vial aerobio y anaerobio en todos los episodios de bacteriemia monomicrobiana por BGN. La prueba de oxidasa se realizó sobre el contenido centrifugado del hemocultivo positivo. Se diseñó un algoritmo para optimizar la realización de la prueba de oxidasa según el TPH y el tipo de vial. Resultados. Se analizaron 341 episodios de bacteriemia por BGN. La sensibilidad, especificidad, valor predictivo positivo y valor predictivo negativo de la prueba de oxidasa para predecir P. aeruginosa fueron del 95%, 99%, 91% y 99%, respectivamente. Cuando el crecimiento se detectó primero o exclusivamente en viales anaerobios, nunca se identificó P. aeruginosa pudiendo evitar la realización de la prueba de oxidasa. Cuando el crecimiento se detectó antes o exclusivamente en viales aerobios un TPH ≥8h predijo la presencia de P. aeruginosa en el 37% de los casos (63 de 169), por lo que es recomendable la realización de la prueba de oxidasa. Conclusiones. La prueba de oxidasa realizada a viales de hemocultivos positivos previamente seleccionados por el TPH y el tipo de medio es una forma fácil y económica de predecir P. aeruginosa. En la mayoría de los casos, esto puede contribuir a la optimización del tratamiento antibiótico en menos de 24h (AU)

Manejo de la candidiasis invasiva en el paciente no neutropénico / Management of invasive candidiasis in non-neutropenic patient

Entre los agentes etiológicos que con mayor frecuencia producen infección nosocomial se incluye Candida spp. La candidemia cursa con tasas de mortalidad superiores al 30%. La instauración temprana de tratamiento antifúngico es esencial para mejorar el pronóstico. A falta de pruebas microbiológicas que permitan establecer un diagnóstico precoz, el tratamiento debe establecerse necesariamente de forma empírica (AU)

Among the most frequents etiological agents that causing nosocomial infections, there is included Candida spp. Candida’s bloodstream infection mortality rates are over 30%. Antifungal early treatment is essential to improve the prognosis of this type of infection. Because of the lack of fast enough microbiological tests for early diagnosis, treatment must necessarily be initiated empirically (AU)