Benefit of an electronic medical record-based alarm in the optimization of stress ulcer prophylaxis.

BACKGROUND: The use of stress ulcer prophylaxis (SUP) has risen in recent years, even in patients without a clear indication for therapy. AIM: To evaluate the efficacy of an electronic medical record (EMR)-based alarm to improve appropriate SUP use in hospitalized patients. METHODS: We conducted an uncontrolled before-after study comparing SUP prescription in intensive care unit (ICU) patients and non-ICU patients, before and after the implementation of an EMR-based alarm that provided the correct indications for SUP. RESULTS: 1627 patients in the pre-intervention and 1513 patients in the post-intervention cohorts were included. The EMR-based alarm improved appropriate (49.6% vs. 66.6%, p<0.001) and reduced inappropriate SUP use (50.4% vs. 33.3%, p<0.001) in ICU patients only. These differences were related to the optimization of SUP in low risk patients. There was no difference in overt gastrointestinal bleeding between the two cohorts. Unjustified costs related to SUP were reduced by a third after EMR-based alarm use. CONCLUSIONS: The use of an EMR-based alarm improved appropriate and reduced inappropriate use of SUP in ICU patients. This benefit was limited to optimization in low risk patients and associated with a decrease in SUP costs.

Intravascular Lymphoma: A Diagnostic Challenge.

Intravascular large B-cell lymphoma (IVLBCL) is a rare type of extranodal large B-cell lymphoma that selectively affects small and medium-sized bloodvessels in the absence oflymph-adenopathy. The central nervous system (CNS) and skin are the organs most commonly affected. We describe the case of a 64-year-old male who presented to the emergency department (ED) complaining of asthenia and bilateral lower extremity edema that progressed rapidly to anasarca. On presentation, laboratory results were significant for elevated erythrocyte sedimentation rate (ESR) and lactate dehydrogenase (LDH) levels. A skin biopsywas performed, which revealed occlusion of blood vessels by atypical immunophenotype B lymphoid cells within the dermis and subcutaneous tissue. The immuno-histochemistry was consistent with IVLB CL. IVLBCL is an aggressive and rapidly fatal neoplasia with varied and nonspecific clinical manifestations, hence, a diagnostic challenge. This case shows an unusual presentation with asthenia and rapidly progressive edema.

Clinical and epidemiological characteristics of patients hospitalized for SARS-CoV-2 infection in two hospitals in Córdoba. / [Características clínicas y epidemiológicas de pacientes hospitalizados por infección por SARS-CoV-2 en dos hospitales en Córdoba.]

Introduction: COVID-19 disease shows a marked heterogeneity in its clinical course, with descriptions of some factors associated with a worse prognosis. Knowledge of the disease behavior in the local scenario is relevant to allow a better approach. Methods: Retrospective study in two hospitals in the city of Córdoba, Argentina, with patients aged 18 years or more, hospitalized for active SARS-CoV-2 infection, from March to October, 2020. Results: 448 patients were included, of which 95.75% corresponded to COVID-19 pneumonia. Most of the episodes occurred in men (63.6%), the median age was 63 years (IQR: 53-75), and the most frequent comorbidities were arterial hypertension (55.1%), obesity (31.7%) and diabetes mellitus (28.1%). 162 patients (36.2%) needed admission to the intensive care unit and 66 (14.7%) were placed on mechanical ventilation. 67 patients (15%) died within the first 30 days of follow-up. In the multivariate analysis, the only independent variable predictive of mortality at 30 days was age (adjusted Odds ratio [aOR] = 1.08, 95% CI = 1.04-1.11, p <0.001). The 4C-Score and CALL-Score prognostic scores showed good discrimination (Area under the curve [AUC] = 0.766, 95% CI = 0.72-0.80 and AUC = 0.785, 95% CI = 0.70-0.85 respectively) and the predicted percentages of mortality were quite close to what was observed in the present study. Conclusions: Most of the patients hospitalized with SARS-CoV-2 infection presented comorbidities and were admitted with pneumonia, associated with high mortality. The prognostic scores with the best performance to predict complications were the 4C-score and the CALL-score.

Introducción: La enfermedad COVID-19 muestra una marcada heterogeneidad en su curso clínico, habiéndose descripto algunos factores que se asocian un peor pronóstico. El conocimiento del comportamiento de la enfermedad en el escenario local es de gran relevancia para permitir un mejor abordaje. Métodos: Estudio retrospectivo en dos hospitales de la ciudad de Córdoba, Argentina, de pacientes de 18 años o más hospitalizados por infección activa por SARS-CoV-2, desde marzo a octubre del año 2020. Resultados: Se incluyeron 448 pacientes, de los cuales el 95.75% correspondieron a neumonía COVID-19. La mayoría de los episodios ocurrieron en hombres (63.6%), la mediana de edad fue 63 años (RIC:53-75), y las comorbilidades más frecuentes fueron hipertensión arterial (55.1%), obesidad (31.7%) y diabetes mellitus (28.1%). Requirieron ingreso a unidad de cuidados intensivos 162 pacientes (36.2%) y 66 (14.7%), asistencia respiratoria mecánica. Fallecieron 67 pacientes (15%) dentro de los primeros 30 días de seguimiento. En el análisis multivariado la única variable independiente predictora de mortalidad a los 30 días fue la edad (Odds ratio ajustado [ORa]=1.08, IC95%=1.04-1.11, p<0.001). Los scores pronósticos 4C-Score y CALL-Score presentaron muy buena discriminación (Área bajo la curva [ABC]=0.766, IC95%=0.72-0.80 y ABC=0.785, IC95%=0.70-0.85, respectivamente) y los porcentajes predichos de mortalidad se aproximaron bastante a lo observado en el presente estudio. Conclusiones: La mayoría de los pacientes hospitalizados por infección por SARS-CoV-2 presentaban comorbilidades y se presentaron como neumonía, asociada a una elevada mortalidad. Los scores pronósticos con mejor rendimiento para predecir complicaciones fueron el 4C-Score y el CALL score.

Urinary tract infections in hospitalized patients.

INTRODUCTION: Urinary Tract Infections (UTI) are an important cause of morbidity in the community, constituting one of the main reasons for hospitalization, and the fourth cause of healthcare-associated infection. The objectives of this study were to determine the frequency of community-acquired UTI (CA-UTI) with need of hospitalization and healthcare-associated UTI (HA-UTI), their risk factors, etiologic agents and their antimicrobial susceptibility spectrum. METHODS: A prospective and analytic study was conducted, in which all admissions regarding CA-UTI with need of hospitalization and HA-UTI were evaluated during the period between 2016 and 2017 in two university hospitals. RESULTS: A total of 279 episodes of UTI in hospitalized patients were identified and, among those, 178 episodes corresponded to CA-UTI and 101 to HA-UTI. On average, patients were 60 years old in both groups. HA-UTI were more frequently associated with kidney transplant, recurrent UTI and chronic kidney disease compared with CA-UTI. The instrumentation of urinary tract within the previous month was more frequent in HA-UTI (75.2% vs 32.6%, p<0.001). Escherichia coli was the most frequent isolated microorganism (62.9% in CA-UTI and 56.4% in HA-UTI), followed by Klebsiella pneumoniae and Pseudomonas aeruginosa. A total of 101 multidrug resistant microorganisms were isolated, of which 53.5% were CA-UTI, and were associated with male patients, use of antimicrobials within the previous three months, chronic kidney disease and recurrent UTI. CONCLUSION: It is of great importance for the institutions to identify the local antimicrobial susceptibility spectrum of UTI in order to stablish adequate empiric treatments.

[Epidemiological and microbiological characteristics of uncomplicated urinary infections]. / Características epidemiológicas y microbiológicas de las infecciones urinarias no complicadas.

Introduction: Uncomplicated urinary tract infections(UC-UTI) represent a frequent reason for consultation. Most cases are empirically treated, but the antimicrobial susceptibility of the causative microorganisms has changed over the past years. The objectives of this study where to determine UC-UTI causative microorganism and their antimicrobial susceptibility profiles in adult women. Methods: A prospective analytic study was conducted in two hospital in Córdoba, Argentina, between November/2016 and October/2017. From the identification of positive urine cultures, urinary tract infections (UTI) in women ≥18 years without risk factors for complicated UTIs were included, excluding asymptomatic bacteriurias. Results: A total of 610 UC-UTI were identified and 62.6% of them in patients younger than 50 years; 73.3% of cases were cystitis, being more frequent in older women. Escherichia coli was isolated in 89.2% of UTI and negative coagulase Staphylococcus in 4.2%. As regards Escherichia coli, its resistance against ciprofloxacin was 18.8%; 4.4% against ceftriaxone and 1.8% against nitrofurantoin. There was an elevated resistance against ampicillin, trimethoprim­sulfamethoxazole and ampicillin­sulbactam. Main conclusion: The most frequent isolated microorganism was Escherichia coli, consistent with global epidemiology. This microorganism showed less than 20% total resistance against ciprofloxacin, ceftriaxone and nitrofurantoin.

Introducción: Las infecciones del tracto urinario no complicadas (ITU-NoC) representan un motivo frecuente de consulta ambulatorio, siendo la mayoría tratadas empíricamente. Han existido cambios en susceptibilidad antimicrobiana en los últimos años. Nuestros objetivos fueron determinar los microorganismos de las ITU-NoC y su perfil de susceptibilidad antimicrobiana en mujeres adultas. Métodos: Estudio analítico prospectivo en dos hospitales de Córdoba, Argentina, entre noviembre/2016 y octubre/2017. A partir de la identificación de urocultivos positivos, se incluyeron las infecciones urinarias(ITUs) en mujeres ≥18 años, sin factores de riesgo para ITUs complicada, excluyéndose las bacteriurias asintomáticas. Resultados: Se identificaron 610 episodios de ITU-NoC, 382(63%) en <50 años. El 73.3% de las ITU-noC correspondieron a cistitis, siendo más frecuentes en las mujeres mayores 50 años.  En el 89.2% de las ITUs se aisló Escherichia coli y 4.2% Staphylococcus coagulasa negativo. Respecto a E. coli, su resistencia a ciprofloxacina fue de 18.8%, ceftriaxona 4.4% y nitrofurantoína 1.8%. Se observó una resistencia elevada a ampicilina, trimetoprima-sulfametoxazol y ampicilina-sulbactam. Conclusiones: En conclusión, el microorganismo más frecuentemente aislado fue E. coli, concordando con la epidemiología global, presentando una resistencia menor al 20% a ciprofloxacina, ceftriaxona y nitrofurantoína.

[Renal Transplantation in a patient with Recessive Dystrophic Epidermolysis Bullosa: a case report] / Reporte de caso: Trasplante Renal en un paciente con Epidermolisis Bullosa.

Recessive dystrophic epidermolysis bullosa (RDEB) is a rare genodermatosis characterized by abnormalities in the anchoring fibrils which attach the basal cell layer of the epidermis to the underlying structures. A characteristic feature of this disorder is the presence of recurrent blistering or erosions, the result of even minor traction to these tissues. Patients with RDEB frequently develop chronic renal failure, and require renal replacement therapy being a major cause of morbidity and mortality. The role of renal transplantation in these patients is scarcely known. We present the case of an end-stage renal disease patient with RDEB treated by renal transplantation and his follow-up during a period of 83 months after the transplant. In this period, there were very low frequency of serious infections as well as the absence of skin tumors. Renal transplantation could be an alternative to renal replacement therapy in epidermolysis bullosa patients with end-stage renal disease, reducing the comorbidities associated with this treatment.

La epidermolisis bullosa distrófica recesiva (EBDR) es una genodermatosis extremadamente infrecuente, caracterizada por la existencia de alteraciones a nivel de las fibras de anclaje que unen la membrana basal de la epidermis a las estructuras subyacentes. Un elemento característico de esta entidad es la formación recurrente de ampollas en piel y mucosas ante traumatismos mínimos, con posterior cicatrización. Los pacientes con EBRD frecuentemente desarrollan enfermedad renal crónica y requieren de terapia de reemplazo renal, constituyendo una importante causa de morbilidad y mortalidad en estos pacientes. El rol del trasplante renal es poco conocido en este tipo de pacientes.Se presenta el caso de un paciente con enfermedad renal terminal y EBDR que es tratado con trasplante renal y su seguimiento a lo largo de un período de 83 meses luego del trasplante. Durante dicho período se observó una baja frecuencia de intercurrencias infecciosas, así como la ausencia de desarrollo de neoplasias cutáneas. El trasplante renal podría ser una alternativa a la terapia de reemplazo dialítica en los pacientes con epidermolisis bullosa asociada a enfermedad renal terminal, reduciendo las comorbilidades asociadas a las terapias dialíticas.

[Uncomplicated urinary tract infection in women: etiology and antimicrobial resistance]. / Infección urinaria no complicada en mujeres: etiología y resistencia a antimicrobianos.

Our objectives were to determine the etiology and analyze the antibiotic resistance profiles of microorganisms causing uncomplicated urinary tract infections in our setting. An analytical cross-sectional study was conducted. In vitro antimicrobial resistance of urine cultures was analyzed. 580 urine cultures of women over age fifteen were included. 82.6 % of urine cultures corresponded to cystitis and the remaining 17.4 % corresponded to pyelonephritis. 353 urine cultures of women <50 years old (60.9%) and 227 of women = 50 years old (39.1%) were obtained. The most common pathogens were Escherichia coli (85.5 %) and Klebsiella pneumoniae (4.7 %). For Escherichia coli, there was a resistance of 28.6% to trimethoprim-sulfamethoxazole,7.9% to ciprofloxacin and 0.4% to nitrofurantoin. Significant difference (p = 0.005) was seen in the resistance to ciprofloxacin in women = 50 years old. Our data show there is a low in vitro resistance to nitrofurantoin

Nuestros objetivos fueron determinar la etiología y analizar los perfiles de resistencia antimicrobiana de los microorganismos causantes de infecciones urinarias no complicadas en nuestro medio. Se realizó un estudio analítico de corte transversal. Se analizó la resistencia antimicrobiana in vitro de los urocultivos. Se incluyeron 580 urocultivos de mujeres mayores de 15 años. Un 82.6% de urocultivos correspondieron a cistitis y el 17.4% a pielonefritis.Se obtuvieron 353 urocultivos de mujeres < 50 años (60.9%) y 227 a ? 50 años (39.1%).Los patógenos más frecuentes fueron: Escherichia coli (85.5%) y Klebsiella pneumoniae (4.7%). Se encontró una resistencia de E coli a trimetoprima-sulfametoxazol del 28.6%, a ciprofloxacina de 7.9% y a nitrofurantoína de 0.4%. Se evidenció diferencia significativa (p=0.005) en la resistencia de E coli a ciprofloxacina en las mujeres ?50 años de edad. Nuestros datos muestran que existe una baja resistencia in vitro a nitrofurantoína.