Plasma Exchange: An Effective Rescue Therapy in Critically Ill Patients With Coronavirus Disease 2019 Infection.

OBJECTIVES: Infection by severe acute respiratory syndrome coronavirus-2 can induce uncontrolled systemic inflammation and multiple organ failure. The aim of this study was to evaluate if plasma exchange, through the removal of circulating mediators, can be used as rescue therapy in these patients. DESIGN: Single center case series. SETTING: Local study. SUBJECTS: Four critically ill adults with coronavirus disease 19 pneumonia that failed conventional interventions. INTERVENTIONS: Plasma exchange. Two to six sessions (1.2 plasma volumes). Human albumin (5%) was used as the main replacement fluid. Fresh frozen plasma and immunoglobulins were administered after each session to avoid coagulopathy and hypogammaglobulinemia. MEASUREMENTS AND MAIN RESULTS: Serum markers of inflammation and macrophage activation. All patients showed a dramatic reduction in inflammatory markers, including the main cytokines, and improved severity scores after plasma exchange. All survived to ICU admission. CONCLUSIONS: Plasma exchange mitigates cytokine storm, reverses organ failure, and could improve survival in critically ill patients with coronavirus disease 2019 infection.

Antibiotic prophylaxis in cirrhosis: Good and bad.

UNLABELLED: Patients with cirrhosis, particularly those with decompensated cirrhosis, are at increased risk of bacterial infections that may further precipitate other liver decompensations including acute-on-chronic liver failure. Infections constitute the main cause of death in patients with advanced cirrhosis, and strategies to prevent them are essential. The main current strategy is the use of prophylactic antibiotics targeted at specific subpopulations at high risk of infection: prior episode of spontaneous bacterial peritonitis, upper gastrointestinal bleeding, and low-protein ascites with associated poor liver function. Antibiotic prophylaxis effectively prevents not only the development of bacterial infections in all these indications but also further decompensation (variceal bleeding, hepatorenal syndrome) and improves survival. However, antibiotic prophylaxis is also associated with a clinically relevant and increasing drawback, the development of infections due to multidrug-resistant organisms. Several strategies have been suggested to balance the risks and benefits of antibiotic prophylaxis. CONCLUSION: Antibiotic stewardship principles such as the restriction of antibiotic prophylaxis to subpopulations at a very high risk for infection, the avoidance of antibiotic overuse, and early deescalation policies are key to achieve this balance; nonantibiotic prophylactic measures such as probiotics, prokinetics, bile acids, statins, and hematopoietic growth factors could also contribute to ameliorate the development and spread of multidrug-resistant bacteria in cirrhosis. (Hepatology 2016;63:2019-2031).

Epidemiology and prognosis of candidaemia in elderly patients.

The aim of the study was to analyse the epidemiology and prognosis of candidaemia in elderly patients. We performed a comparison of clinical presentation of candidaemia according to age and a study of hazard factors within a prospective programme performed in 29 hospitals. One hundred and seventy-six episodes occurred in elderly patients (>75 years), 227 episodes in middle-aged patients (61-75 years) and 232 episodes in younger patients (16-60 years). Central venous catheter, parenteral nutrition, neutropenia, immunosuppressive therapy and candidaemia caused by Candida parapsilosis were less frequent in elderly patients. These patients received inadequate antifungal therapy (57.3%) more frequently than middle-aged and younger patients (40.5% P < .001). Mortality during the first week (20%) and 30 days (42%) was higher in elderly patients. The variables independently associated with mortality in elderly patients during the first 7 days were acute renal failure (OR: 2.64), Pitt score (OR: 1.57) and appropriate antifungal therapy (OR: 0.132). Primary candidaemia (OR: 2.93), acute renal failure (OR: 3.68), Pitt score (OR: 1.38), appropriate antifungal therapy (OR: 0.3) and early removal of the central catheter (OR: 0.47) were independently associated with 30-day mortality.In conclussion, inadequate antifungal treatment is frequently prescribed to elderly patients with candidaemia and is related with early and late mortality.

Executive summary of the diagnosis and treatment of urinary tract infection: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC).

Most urinary tract infections (UTI) are uncomplicated infections occurring in young women. An extensive evaluation is not required in the majority of cases, and they can be safely managed as outpatients with oral antibiotics. Escherichia coli is by far the most common uropathogen, accounting for >80% of all cases. Other major clinical problems associated with UTI include asymptomatic bacteriuria, and patients with complicated UTI. Complicated UTIs are a heterogeneous group associated with conditions that increase the risk of acquiring infection or treatment failure. Distinguishing between complicated and uncomplicated UTI is important, as it influences the initial evaluation, choice, and duration of antimicrobial therapy. Diagnosis is especially challenging in the elderly and in patients with in-dwelling catheters. The increasing prevalence of resistant uropathogens, including extended-spectrum ß-lactamases and carbapenemase-producing Enterobacteriaceae, and other multidrug-resistant Gram-negative organisms further compromises treatment of both complicated and uncomplicated UTIs. The aim of these Clinical Guidelines is to provide a set of recommendations for improving the diagnosis and treatment of UTI.

Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study.

UNLABELLED: Epidemiology, risk factors, and clinical effect of infections by multiresistant bacteria in cirrhosis are poorly known. This work was a prospective evaluation in two series of cirrhotic patients admitted with infection or developing infection during hospitalization. The first series was studied between 2005 and 2007 (507 bacterial infections in 223 patients) and the second between 2010 and 2011 (162 bacterial infections in 110 patients). In the first series, 32% of infections were community acquired (CA), 32% healthcare associated (HCA), and 36% nosocomial. Multiresistant bacteria (92 infections; 18%) were isolated in 4%, 14%, and 35% of these infections, respectively (P < 0.001). Extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E; n = 43) was the main multiresistant organism identified, followed by Pseudomonas aeruginosa (n = 17), methicillin-resistant Staphylococcus aureus (n = 14), and Enterococcus faecium (n = 14). The efficacy of currently recommended empirical antibiotic therapy was very low in nosocomial infections (40%), compared to HCA and CA episodes (73% and 83%, respectively; P < 0.0001), particularly in spontaneous bacterial peritonitis, urinary tract infection, and pneumonia (26%, 29%, and 44%, respectively). Septic shock (26% versus 10%; P < 0.0001) and mortality rate (25% versus 12%; P = 0.001) were significantly higher in infections caused by multiresistant strains. Nosocomial origin of infection (hazard ratio [HR], 4.43), long-term norfloxacin prophylaxis (HR, 2.69), recent infection by multiresistant bacteria (HR, 2.45), and recent use of ß-lactams (HR, 2.39) were independently associated with the development of multiresistant infections. Results in the second series were similar to those observed in the first series. CONCLUSIONS: Multiresistant bacteria, especially ESBL-producing Enterobacteriaceae, are frequently isolated in nosocomial and, to a lesser extent, HCA infections in cirrhosis, rendering third-generation cephalosporins clinically ineffective. New antibiotic strategies tailored according to the local epidemiological patterns are needed for the empirical treatment of nosocomial infections in cirrhosis.

Influence of multidrug resistance and appropriate empirical therapy on the 30-day mortality rate of Pseudomonas aeruginosa bacteremia.

Infections due to multidrug-resistant (MDR) Pseudomonas aeruginosa are increasing. The aim of our study was to evaluate the influences of appropriate empirical antibiotic therapy and multidrug resistance on mortality in patients with bacteremia due to P. aeruginosa (PAB). Episodes of PAB were prospectively registered from 2000 to 2008. MDR was considered when the strain was resistant to ≥3 antipseudomonal antibiotics. Univariate and multivariate analyses were performed. A total of 709 episodes of PAB were studied. MDR PAB (n = 127 [17.9%]) was more frequently nosocomial and associated with longer hospitalization, bladder catheter use, steroid and antibiotic therapy, receipt of inappropriate empirical antibiotic therapy, and a higher mortality. Factors independently associated with mortality were age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002 to 1.033), shock (OR, 6.6; 95% CI, 4 to 10.8), cirrhosis (OR, 3.3; 95% CI, 1.4 to 7.6), intermediate-risk sources (OR, 2.5; 95% CI, 1.4 to 4.3) or high-risk sources (OR, 7.3; 95% CI, 4.1 to 12.9), and inappropriate empirical therapy (OR, 2.1; 95% CI, 1.3 to 3.5). To analyze the interaction between empirical therapy and MDR, a variable combining both was introduced in the multivariate analysis. Inappropriate therapy was significantly associated with higher mortality regardless of the susceptibility pattern, and there was a trend toward higher mortality in patients receiving appropriate therapy for MDR than in those appropriately treated for non-MDR strains (OR, 2.2; 95% CI, 0.9 to 5.4). In 47.9% of MDR PAB episodes, appropriate therapy consisted of monotherapy with amikacin. In conclusion, MDR PAB is associated with a higher mortality than non-MDR PAB. This may be related to a higher rate of inappropriate empirical therapy and probably also to amikacin as frequently the only appropriate empirical therapy given to patients with MDR PAB.

New trends in infective endocarditis.

The present article is an update of the literature on endocarditis. A multidisciplinary group of Spanish physicians with an interest in cardiac infections selected the most important papers produced lately in the field. Two of the members of the group discussed the content of each of the selected papers, with a critical review by others members of the panel. After a review of the state of the art papers from the fields of epidemiology, new causative microorganisms (bacterial and fungal), clinical findings including those in special patients, laboratory diagnosis, prognostic factors, nosocomial endocarditis, prophylaxis, new drugs and guidelines for antibiotic treatment were discussed by the group.

[Guidelines for the treatment of Invasive Candidiasis and other yeasts. Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). 2010 Update]. / Recomendaciones sobre el tratamiento de la candidiasis invasiva y otras infecciones por levaduras de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC). Actualización 2011.

These guidelines are an update of the recommendations of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) that were issued in 2004 (Enferm Infecc Microbiol Clin. 2004, 22:32-9) on the treatment of Invasive Candidiasis and infections produced by other yeasts. This 2010 update includes a comprehensive review of the new drugs that have appeared in recent years, as well as the levels of evidence for recommending them. These guidelines have been developed following the rules of the SEIMC by a working group composed of specialists in infectious diseases, clinical microbiology, critical care medicine, paediatrics and oncology-haematology. It provides a series of general recommendations regarding the management of invasive candidiasis and other yeast infections, as well as specific guidelines for prophylaxis and treatment, which have been divided into four sections: oncology-haematology, solid organ transplantation recipients, critical patients, and paediatric patients.

Validation of the American Thoracic Society-Infectious Diseases Society of America guidelines for hospital-acquired pneumonia in the intensive care unit.

BACKGROUND: The 2005 guidelines of the American Thoracic Society-Infectious Diseases Society of America Guidelines for Hospital for managing hospital-acquired pneumonia classified patients according to time of onset and risk factors for potentially drug-resistant microorganisms to select the empirical antimicrobial treatment. We assessed the microbial prediction and validated the adequacy of these guidelines for antibiotic strategy. METHODS: We prospectively observed 276 patients with intensive care unit-acquired pneumonia. We classified patients into group 1 (early onset without risk factors for potentially drug-resistant microorganisms; 38 patients) and group 2 (late onset or risk factors for potentially drug-resistant microorganisms; 238 patients). We determined the accuracy of guidelines to predict causative microorganisms and the influence of guidelines adherence in patients' outcome. RESULTS: Microbial prediction was lower in group 1 than in group 2 (12 [50%] of 24 vs 119 [92%] of 129; P < .001) mainly because of potentially drug-resistant microorganisms in 10 patients (26%) from group 1. Guideline adherence was higher in group 2 (153 [64%] vs 7 [18%]; P < .001). Guideline adherence resulted in more treatment adequacy than did nonadherence (69 [83%] vs 45 [64%]; P = .013) and a trend toward better response to empirical treatment in group 2 only but did not influence mortality. Reclassifying patients according to the risk factors for potentially drug-resistant microorganisms of the former 1996 American Thoracic Society guidelines increased microbial prediction in group 1 to 21 (88%; P = .014); all except 1 patient with potentially drug-resistant microorganisms were correctly identified by these guidelines. CONCLUSIONS: The 2005 guidelines predict potentially drug-resistant microorganisms worse than the 1996 guidelines. Adherence to guidelines resulted in more adequate treatment and a trend to a better clinical response in group 2, but it did not influence mortality.

Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission.

BACKGROUND: The recent Infectious Disease Society of America/American Thoracic Society guidelines for the management of community-acquired pneumonia (CAP) in adults defined a predictive rule to identify patients with severe CAP to determine the need for intensive care unit (ICU) admission. We clinically validated this rule. METHODS: We analyzed 2102 episodes of CAP in consecutively hospitalized patients over a 7-year period. The predictive rule consists of at least 1 of 2 major severity criteria (septic shock and invasive mechanical ventilation) or at least 3 of 9 minor severity criteria. We assessed the association of the predictive rule with ICU admission and mortality. RESULTS: A total of 235 episodes of CAP (11%) occurred in patients who were admitted to the ICU, whereas the predictive rule identified 397 (19%) of 2102 episodes as severe CAP. The predictive rule and the decision for ICU admission agreed in 1804 (86%) of the episodes (kappa coefficient, 0.45), with a sensitivity of 71% and a specificity of 88%, similar to the 2001 American Thoracic Society guidelines (sensitivity, 66%; specificity, 90%) in predicting ICU admission. Severe CAP criteria had higher sensitivity (58% vs. 46%) and similar specificity (88% vs. 90%), compared with the 2001 American Thoracic Society guidelines in predicting hospital mortality. Invasive mechanical ventilation was the main determinant for ICU admission, followed by septic shock. In the absence of major criteria, ICU admission was not related to survival of patients with minor severity criteria. CONCLUSIONS: The predictive rule to identify severe CAP is accurate for ICU admission and improved the prediction of mortality, compared with the previous American Thoracic Society guidelines. The need for ICU admission derived from minor severity criteria alone is uncertain and deserves further investigation.

Treatment of critically ill patients with candidemia.

Early initiation of effective antimicrobial therapy is crucial for the prognosis of any infection, especially in the critically ill patient. This is particularly true in the case of candidemia. However, the earlier an empirical antimicrobial regimen is started, the greater the probability of diagnostic error and the possibility of side-effects. Recent experience of the clinical efficacy and good tolerance of echinocandins in the treatment of candidemia obliges us to review the indications for empirical antifungal treatment and the choice of antifungal agent in the critically ill patient.

Update on bacterial pathogens: virulence and resistance.

The present article is an update of the literature on bacterial pathogens. Recognizing the interest and scientific and public health importance of infections produced by bacterial pathogens with new virulence mechanisms and/or new mechanisms of resistance to antimicrobial agents, a multidisciplinary group of Spanish physicians and microbiologists organized a joint session and revised the most important papers produced in the field during 2006. Each article was analyzed and discussed by one of the members of the panel. This paper focus on a variety of diseases that pose major clinical and public health challenges today; and include infections produced by community-acquired methicillin-resistant Staphylococcus aureus and S. aureus small colony variants, infections produced by multiply resistant coagulase-negative staphylococci, pneumococcal infections, human listeriosis, meningococcal disease, Haemophilus influenzae, pertussis, Escherichia coli, ESBL-producing organisms, and infections due to non-fermenters. After a review of the state of the art, papers selected in this field are discussed.

El presente artículo recoge una actualización bibliográfica de patógenos bacterianos. Dado el interés científico y la importancia que tienen para la salud pública las infecciones producidas por patógenos bacterianos con nuevos mecanismos de virulencia y/o nuevos mecanismos de resistencia a los antimicrobianos, un grupo multidisciplinario de microbiólogos y clínicos españoles, con experiencia en enfermedades infecciosas, organizó una reunión en la que se revisaron los artículos más importantes en este campo, publicados en 2006.El contenido de cada uno de los artículos seleccionados fue expuesto y discutido por uno de los miembros del grupo. Este artículo revisa algunas de las enfermedades infecciosas bacterianas que suponen hoy en día algunos de los principales retos para la salud pública e incluye las infecciones producidas por Staphylococcus aureus resistente a meticilina de adquisición comunitaria, las producidas por variantes de colonia pequeña de S. aureus, las relacionadas con estafilococos coagulasa negativa multirresistentes, la infección neumocócica, la listeriosis humana, la infección meningocócica, la tos ferina, las infecciones por Haemophilus influenzae, la diseminación de las bacterias productoras de BLEE, y las infecciones por bacilos gramnegativos no fermentadores. Tras la revisión de la situación actual, se discuten y comentan diferentes artículos relacionados con estos aspectos.

Impact of alcohol abuse in the etiology and severity of community-acquired pneumonia.

BACKGROUND AND STUDY OBJECTIVES: Alcohol consumption is known to affect both systemic and pulmonary immunity, predisposing the patient to pulmonary infections. The aim of this study was to compare the etiology of disease, the antibiotic resistance of Streptococcus pneumoniae, the severity of disease, and the outcome of patients with alcohol abuse to those of nonalcoholic (NA) patients who have been hospitalized for community-acquired pneumonia (CAP). METHODS: From 1997 to 2001, clinical, microbiological, radiographic, and laboratory data, and follow-up variables of all consecutive patients who had been hospitalized with CAP were recorded. Patients were classified as alcoholic (A) [n = 128] or ex-alcoholic (EA) patients (n = 54) and were compared to NA patients (n = 1,165). RESULTS: S pneumoniae was found significantly more frequently in all patients with alcohol misuse. As regards the rates of antibiotic resistance, invasive pneumococcal disease, and other microorganisms, no differences were found. The severity criteria for CAP according to the American Thoracic Society were more frequent in A patients, but mortality did not differ significantly. Multivariate analysis showed an independent association between pneumococcal CAP and alcoholism (A patients: odds ratio [OR], 1.6; p = 0.033; EA patients: OR, 2.1; p = 0.016). CONCLUSIONS: We found an independent association between pneumococcal infection and alcoholism. Current alcohol abuse was associated with severe CAP. No significant differences were found in mortality, antibiotic resistance of S pneumoniae, and other etiologies.

Rapid Diagnosis of Staphylococcal Catheter-Related Bacteraemia in Direct Blood Samples by Real-Time PCR.

Catheter-related bacteremia (CRB) is an important cause of morbidity and mortality among hospitalized patients, being staphylococci the main etiologic agents. The objective of this study was to assess the use of a PCR-based assay for detection of staphylococci directly from blood obtained through the catheter to diagnose CRB caused by these microorganisms and to perform a cost-effectiveness analysis. A total of 92 patients with suspected CRB were included in the study. Samples were obtained through the catheter. Paired blood cultures were processed by standard culture methods and 4 ml blood samples were processed by GeneXpert-MRSA assay for the detection of methicillin-susceptible (MSSA) or methicillin-resistant (MRSA) Staphylococcus aureus, and methicillin-resistant coagulase-negative staphylococci (MR-CoNS). Sixteen CRB caused by staphylococci were diagnosed among 92 suspected patients. GeneXpert detected 14 out of 16 cases (87.5%), including 4 MSSA and 10 MR-CoNS in approximately 1 hour after specimen receipt. The sensitivity and specificity of GeneXpert were 87.5% (CI 95%: 60.4-97.8) and 92.1% (CI 95%: 83-96.7), respectively, compared with standard culture methods. The sensitivity of GeneXpert for S. aureus was 100%. Regarding a cost-effectiveness analysis, the incremental cost of using GeneXpert was of 31.1€ per patient while the incremental cost-effectiveness ratio of GeneXpert compared with blood culture alones was about 180€ per life year gained. In conclusion, GeneXpert can be used directly with blood samples obtained through infected catheters to detect S. aureus and MR-CoNS in approximately 1h after sampling. In addition, it is cost-effective especially in areas with high prevalence of staphylococcal CRB.

Assessment of the usefulness of sputum culture for diagnosis of community-acquired pneumonia using the PORT predictive scoring system.

BACKGROUND: The usefulness of sputum culture in guiding microbiological diagnosis of community-acquired pneumonia is controversial. We evaluate and assess it using the Patients Outcome Research Team (PORT) predictive scoring system. METHODS: A cohort of 1669 patients with community-acquired pneumonia was studied. Before administering antibiotic therapy, sputum was collected and its quality evaluated. Samples were gram stained and those of good quality were assessed for a predominant morphotype (PM). Sputum cultures were processed according to standard protocols. RESULTS: A sputum sample was obtained from 983 (59%) of the 1669 patients and 532 (54%) of the samples were of good quality. There was a PM in 240 (45%) of the latter samples (ie, for 14.4% of the 1669 patients) and there was no PM in 292 (55%). Culture yielded a microorganism in 207 (86%) of the 240 samples with PM and 57 (19.5%) of the 292 samples without PM (P<.05). Rates of sputum obtained, good-quality sputum specimens, PM identification, and positive culture were not significantly different among the PORT-score groups of patients (P>.05). The sensitivity and specificity of the gram-positive diplococci identification in the sputum culture of Streptococcus pneumoniae were 60% and 97.6%, and the positive and negative predictive values were 91% and 85.3%, respectively. CONCLUSIONS: Good-quality sputum with PM could be obtained in only 14.4% of all patients. A PORT-score group in which sputum could be of greater usefulness in identifying the causative organism could not be identified. The presence of gram-positive diplococci in gram-stained sputum culture was highly specific for S pneumoniae.

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

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.

Blood cultures for women with uncomplicated acute pyelonephritis: are they necessary?

To assess the utility of blood cultures in the management of uncomplicated pyelonephritis in women, we prospectively collected data from 583 cases. Discordant cases were defined as those for which the pathogens isolated from urine and from blood were different. We found that 97.6% of cases were nondiscordant. Clinical and microbiological evolution of infection did not differ between the 2 groups, and no changes of antibiotic therapy were required on the basis of blood culture results. Blood culture may not be routinely required for the evaluation of uncomplicated pyelonephritis in women.

Viral community-acquired pneumonia in nonimmunocompromised adults.

INTRODUCTION: Viral community-acquired pneumonia (CAP) has been poorly studied and clinically characterized. Using strict criteria for inclusion, we studied this type of infection in a large series of hospitalized adults with CAP. MATERIALS AND METHODS: All nonimmunocompromised adult patients with a diagnosis of CAP having paired serology for respiratory viruses (RVs) [338 patients] were prospectively included in the study from 1996 to 2001 at our 1,000-bed university teaching hospital, and subsequently were followed up. We compared patients with pure viral (PV), mixed viral (RV + bacteria), and pneumococcal CAP. RVs (ie, influenza, parainfluenza, respiratory syncytial virus, and adenovirus) were diagnosed by means of paired serology. RESULTS: Sixty-one of 338 patients (18%) with paired serology had an RV detected, and in 31 cases (9%) it was the only pathogen identified. Influenza was the most frequent virus detected (39 patients; 64%). Patients with chronic heart failure (CHF) had an increased risk of acquiring PV CAP (8 of 26 patients; 31%) when compared to a mixed viral/bacterial etiology (2 of 26 patients; 8%; p = 0.035) or CAP caused by Streptococcus pneumoniae (1 of 44 patients; 2%; p = 0.001). Multivariate analysis revealed that CHF (odds ratio [OR], 15.3; 95% confidence interval [CI], 1.4 to 163; p = 0.024) and the absence of expectoration (OR, 0.14; 95% CI, 0.04 to 0.6; p = 0.006) were associated with PV pneumonia compared to pneumococcal CAP. CONCLUSION: RVs are frequent etiologies of CAP (single or in combination with bacteria). Patients with CHF have an increased risk of acquiring a viral CAP.