Bacteraemia due to extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) in cancer patients: clinical features, risk factors, molecular epidemiology and outcome.

OBJECTIVES: To assess the clinical features, risk factors, molecular epidemiology and outcome of extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) bacteraemia in hospitalized cancer patients. METHODS: Episodes of ESBL-EC bacteraemia were compared with a susceptible control group in a 3 year prospective study. ESBL-EC strains were studied by PCR and isoelectric focusing, and molecular typing was performed by PFGE. RESULTS: Out of 531 episodes of bacteraemia, 135 were caused by E. coli. Seventeen of these cases involved ESBL-EC-producing strains (12.6%). In the multivariate analysis, female gender [odds ratio (OR) 3.43; 95% confidence interval (CI) 1.03-11.4] and previous antibiotic therapy (OR 3.22; 95% CI 1.00-10.3) were found to be independent risk factors for ESBL acquisition. An analysis of ESBL-EC isolates revealed a polyclonal distribution with CTX-M predominance (59%). Patients with ESBL-EC bacteraemia were more likely to have received an inadequate empirical antibiotic therapy (65% versus 6%; P = 0.000), and the time to adequate therapy was longer in this group (0 versus 1.50 days; P = 0.000). The overall mortality rate was 22%, ranging from 20% to 35% (P = 0.20). Risk factors for mortality were solid tumour (OR 19.41; 95% CI 4.66-80.83), corticosteroid therapy (OR 3.04 95% CI 1.05-8.81) and intensive care unit admission (OR 248.24, 95% CI 18.49-3332.14). In neutropenic patients, ESBL-EC bacteraemia was associated with poorer outcome and a higher overall mortality rate (37.5% versus 6.5%; P = 0.01). CONCLUSIONS: In our centre, ESBL-EC bacteraemia is frequent among cancer patients, especially in those exposed to antibiotic pressure. All ESBL-EC strains were unrelated and most of them carried a CTX-M group enzyme. Patients with ESBL-EC bacteraemia received inadequate empirical antibiotic therapy more frequently than patients carrying a susceptible strain, but significant differences in mortality could not be demonstrated.

[Impact of a prevention program for catheter-related bloodstream infection in the intensive care unit of a tertiary hospital]. / Impacto de un programa de prevención de la bacteriemia relacionada con el catéter en una unidad de cuidados intensivos de un hospital terciario.

INTRODUCTION: Catheter-related bloodstream infection (CR-BSI) is a cause of morbidity and mortality in intensive care units, and the optimal approach for preventing these infections is not well defined. Comparison of CR-BSI rates with those provided by programs such as the National Nosocomial Infection Surveillance System (NNISS) from the USA and the Spanish National Nosocomial Infection Surveillance Study (ENVIN), enable determination of the need to implement control measures. In 2000, we found that the CR-BSI rates in UCIs of our hospital were much higher than the data reported by ENVIN. OBJECTIVE: To assess the impact of implementing a protocol for proper use of intravascular catheters on CR-BSI rates in the intensive care unit (ICU) of a tertiary hospital. METHODS: Prospective study of patients admitted to the ICUs of a tertiary hospital in the months of May and June, from 2000 to 2004. In 2001, a CR-BSI prevention program including aspects related to catheter insertion and maintenance in ICU patients was implemented. We calculated infection rates per 1000 days of catheter use in all the 2-month periods studied, and compared the 2000 and 2004 results by analysis of the odds ratios and confidence intervals. RESULTS: A total of 923 patients were included. Mean age was 58.7 years (SD: 15.4), mean ICU stay was 11.6 days (SD: 11.4), mean SAPSII was 28.2 (SD: 15.9), and mortality was 20.5%. There was a significant reduction in CR-BSI rates from 13.3 episodes per 1000 days of catheter use in the first period to 3.21 in the last period (OR=3.53, 95% CI: 2.36-5.31). CONCLUSIONS: Application of a prevention program for CR-BSI and a system for monitoring BSI rates led to a significant, sustained reduction in these infections.

Community-acquired bacterial meningitis in elderly patients: experience over 30 years.

Clinical characteristics, etiologies, evolution, and prognostic factors of community-acquired bacterial meningitis in elderly patients are not well known. To improve this knowledge, all episodes of community-acquired bacterial meningitis were prospectively recorded and cases occurring in patients >or=65 years old were selected. During the period 1977-2006, 675 episodes in adults (aged >or=18 yr) were recorded, with 185 (27%) in patients aged >or=65 years old; 76 were male and 109 were female, with a mean age of 73 +/- 6 years (range, 65-93 yr). Causative microorganisms were Streptococcus pneumoniae 74, Neisseria meningitidis 49, Listeria monocytogenes 17, other streptococcal 9, Escherichia coli 6, Haemophilus influenzae 4, Klebsiella pneumoniae and Staphylococcus aureus 2 each, Capnocytophaga canimorsus and Enterococcus faecalis 1 each, and unknown in 20. On admission 91% had had fever, 32% were in a coma (Glasgow Coma Scale or=65 yr), who showed a higher frequency of diabetes and malignancy as underlying disease; pneumonia, otitis, and pericranial fistula as predisposing factors; and S. pneumoniae and L. monocytogenes as etiology. There were also differences in clinical presentation, complications, sequelae, and mortality. Factors independently related with mortality were age, pneumonia as a predisposing factor, coma on admission, and heart failure and seizures after therapy. Dexamethasone therapy was a protective factor. In conclusion, bacterial meningitis in elderly patients is associated with greater diagnostic difficulties and neurologic severity and more complications, as well as with increased mortality. Antiseizure prophylaxis might be useful in these patients.

Epidemiological and clinical characteristics of bacteraemia caused by Aeromonas spp. as compared with Escherichia coli and Pseudomonas aeruginosa.

We reviewed 75 episodes of Aeromonas spp. bacteraemia observed at our institution in 1979-2002, with special reference to episodes occurring in elderly patients (> or = 65 y) and to nosocomial episodes. In addition, we compared monomicrobial bacteraemic episodes caused by Aeromonas spp. (n = 54) with those caused by Escherichia coli (n = 108) and Pseudomonas aeruginosa (n = 108), to assess differences in clinical presentation and outcome. The 75 episodes of Aeromonas spp. bacteraemia occurred mainly in males (72%), suffering from chronic liver disease (36%) or neoplasm (33%). They had an abdominal origin in 52% of cases, were recorded as primary bacteraemia in 40%, and showed a 30-d case fatality rate of 36%. 22 episodes (29%) were nosocomial, 36 (48%) occurred in elderly patients and 21 (28%) were polymicrobial infections. In comparison with Aeromonas spp., E. coli bacteraemia was more often associated with less severe underlying conditions, a community-acquired infection (74%), and a urinary tract (52%) or abdominal (27%) origin and had a 30-d case fatality rate of 24%. P. aeruginosa bacteraemia occurred mainly in patients with severe underlying conditions, was associated with nosocomial infection (69%), and had a 30-d case fatality rate of 43%. In conclusion, Aeromonas spp. bacteraemia is a serious infection that should be considered in patients with chronic liver disease or neoplasm. It may occur in the elderly and as a nosocomial infection, and differs in clinical findings from bacteraemia due to other common pathogens.