[Results of implementation of a pilot antimicrobial stewardship program (ASP) in Primary Care].

BACKGROUND: The aim of this study was to evaluate the implementation of a pilot antimicrobial stewardship program (ASP) in Primary Health Care teams (PHCT) in Navarre (Spain). MATERIAL AND METHODS: Non-randomized experimental study performed with data obtained from the electronic pharmacy records. Differences in consumption of antibiotics before (2018) and after (2019) ASP implementation in twelve PHCT were calculated. Another twelve PHCT without ASP were used for comparison. We analysed data on global and beta-lactams, fluoroquinolones, macrolides, cephalosporines and fosfomycin-trometamol, expressed in number of treated patients and DDD (defined daily doses). RESULTS: The number of patients with prescribed antibiotics decreased significantly more in PHCT with ASP (-9.1 vs. -1.7%), particularly with fluoroquinolones (-25 vs. -20.4%), macrolids (-20.4 vs. -8.5%) and amoxicillin-clavulanic (-10.3 vs. -2.5%). Decreased DDD followed the same pattern. Both PHCT groups kept constant the number of patients with prescribed third generation cephalosporins, while those with prescribed first generation cephalosporins and betalactamase-sensible penicilins increased similarly. In PHCT with ASP, increased number of patients with prescribed phos-phomycin-trometamol was smaller (4.0 vs. 11.5%) while its consumption expressed in DDDs was reduced while increasing in PHCT without ASP (-1 vs. 10%, p<0.001).

[Uncomplicated urinary tract infections. Antimicrobial susceptibility study in Navarre]. / Infecciones del tracto urinario. Estudio de sensibilidad antimicrobiana en Navarra.

BACKGROUND: Urinary tract infection (UTI) is a high prevalence infection at the community level. In order to improve the adequacy of the empirical therapy, we evaluated the etiology and the resistance pattern of the main uropathogens responsible for community acquired UTI in Navarre. METHODS: Retrospective study (2014-2016) in which we included microorganisms recovered with significant counts from samples of patients with community-acquired UTI. The global etiology and etiology according to age and sex was analyzed. Antimicrobial resistance was studied with urotopathogens isolated in 2016. RESULTS: Escherichia coli was the most frequently isolated microorganism both in the population (60.8%) and in each of the groups analyzed according to age and sex. The sensitivity of E. coli was: nitrofurantoin 97.4%, fosfomycin 96.5% amoxicillin-clavulanic acid 83.8%, trimethoprim-sulfamethoxazole 68.3%, quinolones 63.4% and amoxicillin 41.9%. Pooled sensitivity shows that the sensitivity to fosfomycin was 83.4% in men <15 years, 89.4% in women <15 years and 81.9% in women between 15-65 years; and to nitrofurantoin was 86.7% in women <15 years and 82.2% in women between 15-65 years. CONCLUSIONS: E. coli continues to be the most frequent microorganism in community-acquired UTI with a rate of sensitivity to fosfomycin and nitrofurantoin above 95%. The empirical treatment of UTI in our environment should not include amoxicillin, amoxicillin-clavulanic acid, trimethoprim-sulfamethoxazole or quinolones. Fosfomycin may be empirically used in the treatment of uncomplicated cystitis in men younger than 15 years and in women under 65 years, and nitrofurantoin may be used empirically in women under 65 years.

[Aetiology and antibiotic sensitivity of the most frequent outpatient infections]. / Etiología y sensibilidad antibiótica de las infecciones extrahospitalarias más frecuentes.

The diffusion of the outlines of antibiotic sensitivity is a practice that is recommended for improving the prescription of antibiotics and for controlling the appearance and spread of resistances. During the years 2003 and 2004, data was gathered on the sensitivity to antibiotics of the main bacteria isolated in outpatient urine cultures, coprocultures, faringoamygdal and otic smears in the Pamplona health area, which attends to a population of approximately 400,000 inhabitants. Of the 9,495 uropathogens isolated, 90% were sensitive to amoxicillin-clavulanate, 96.4% to 2nd generation cephalosporins, 95.3% to phosphomycin and 97.7% to nitrofurantoin. One point eight percent (1.8%) of the strains of Escherichia coli isolated in urine were producers of extended spectrum b-lactamases, while 0.5% of the urinary isolations of Klebsiella pneumoniae were producers of this type of b-lactamases. Ninety-six point five percent of the 797 isolations of Salmonella serotipo Enteritidis were sensitive to cotrimoxazol, and 97.5% of the 1,057 isolations of Campylobacter jejuni were sensitive to eritromycine. Of the 319 bacteria isolated in otitis media, 96.5% were sensitive to amoxyline. The Gram negative bacillae producers of otitis externa showed a sensitivity above 90% to ciprofloxacin, gentamycin and polimixin B. Twenty-nine point seven percent of the isolations of Streptococcus pyogenes were resistant to eritromycine. Fourteen point three percent and 17.4% of the Staphylococcus aureus isolated in the years 2003 and 2004 respectively were resistant to methicillin. Knowledge of the map of antibiotic sensitivity of the microorganisms in circulation in each geographical area is information that is necessary for the empirical choice of antibiotic treatment.

Evaluation of the MB/BacT system compared with Middlebrook 7H11 and Lowenstein-Jensen media for detection and recovery of mycobacteria from clinical specimens.

MB/BacT vials (an automated system), Middlebrook 7H11 agar plates with the microcolony method for growth detection, and conventional Lowenstein-Jensen egg-based medium were assessed for their rates of recovery, time to detection and ease in aiding the identification of mycobacterial isolates. Of the 2101 consecutive, non-selected specimens for tuberculosis analysed in the laboratory, 158 (7.5%) yielded growth of 159 mycobacteria on at least one of the three media, comprising 111 Mycobacterium tuberculosis and 48 non-tuberculous mycobacteria. Of the 111 specimens positive for M. tuberculosis, 100 isolates were recovered from MB/BacT vials, 99 from M7H11 agar plates, and 86 from Lowenstein-Jensen tubes. The combination of MB/BacT and M7H11 recovered 110 isolates of M. tuberculosis, 107 from M7H11 and Lowenstein-Jensen, and 105 from MB/BacT plus Lowenstein-Jensen. The average time to detection of M. tuberculosis was 11 days with M7H11 using the microcolony method, 16 days with MB/BacT, and 19.5 days with the conventional Lowenstein-Jensen method. The MB/BacT vials recovered greater numbers of non-tuberculous mycobacteria than either of the other two media, but these were considered mostly to be saprophytes. It was concluded that a combination of media was better than a single medium. None of the media combinations showed statistical differences. Use of M7H11 with the microcolony method, which shortens the detection time for mycobacteria and facilitates the detection of mixed cultures, together with the Lowenstein-Jensen tube, was a useful combination.

Transmission of Streptococcus pyogenes causing successive infections in a family.

The objective of this study was to determine the characteristics of Streptococcus pyogenes isolated during a 10-month period from members of a family with infections and asymptomatic carriage. T-serotyping and pulsed-field gel electrophoresis confirmed that distinct GAS clones were introduced into the family over a short period of time.

[Aetiology and antibiotic sensitivity of the most frequent outpatient infections, except those of the lower respiratory tract]. / Etiología y sensibilidad antibiótica de las infecciones extrahospitalarias más frecuentes, excepto las del tracto respiratorio inferior.

Reporting of antimicrobial susceptibility profiles is recommended in order to improve antibiotic prescribing policies and to avoid the emergence of bacterial resistance. During 2001, susceptibility data from bacterial isolates collected from urine, faeces and ear swabs and antimicrobial susceptibility for Streptococcus pyogenes during the first five months in 2002 were recorded in the Health Area of Pamplona (389,489 inhabitants) and compared against data for antibiotic prescriptions. More than 80% of bacteria from urine were susceptible to amoxicillin plus clavulanic acid, oral cephalosporins, fosfomycin and nitrofurantoin. Of the Salmonella Enteritidis isolates, 98.3% were susceptible to trimethroprim-sulfamethoxazole and 96.6% of Campylobacter jejuni to erythromycin. Amoxicillin remained susceptible for more than 95.5% of middle ear isolates. Gram-negative bacilli isolates from otitis externa swabs were susceptible to ciprofloxacin, gentamicin and polimyxin B in over 80% of cases. Of the Streptococcus pyogenes isolated, 22.5% were resistant to erythromycin. Antimicrobial consumption in defined daily doses per 1,000 inhabitants, day (DID) during 2001 was 14.8. Here, we highlight the over-prescription of some broad-spectrum antibiotics and macrolides for the empiric treatment of infectious diseases in our area. Knowledge of local susceptibility patterns is essential in order to inform empiric therapy.

[Antibiotic sensitivity and treatment recommendations for Streptococcus pneumoniae]. / Sensibilidad antibiótica y recomendaciones de tratamiento para Streptococcus pneumoniae.

The aims of present paper were to determine the susceptibility of the strains to the most usual antibiotics in clinical practice and to review the current recommendations to guide the most appropriate treatment. During the period october 2000 to september 2002, the patient's data (age and sex), source of the sample, diagnosis and antibiotic susceptibility were collected on Streptococcus pneumoniae isolates from microbiology laboratories in the Navarra region (555.829 inhabitants). Four hundred and sixty five isolates were identified (166 from invasive infections). Generally, isolates from ear swabs were the most resistant to the antimicrobials tested, while those from blood culture were the most susceptible. Of the Streptococcus pneumoniae tested, 43% were resistant to penicillin, 6.1% to amoxicillin and 6.6% to cefotaxime. Of the 36.3% of Streptococcus pneumoniae isolates that were resistant to erythromycin, 85.45% exhibited the MLSB phenotype while the remaining 14.55% presented with the M phenotype. Multiple-resistance was detected in 32.3% of the strains. The antibiotic resistance rates to beta-lactams (specially penicillin, amoxicillin and cefotaxime/ceftrixone) in Streptococcus pneumoniae don't prevent its clinical use for the most of Streptococcus pneumoniae isolated in our area, except for pneumococcal meningitis.

Changing epidemiology of invasive pneumococcal disease following increased coverage with the heptavalent conjugate vaccine in Navarre, Spain.

The present study evaluated changes in the incidence of invasive pneumococcal disease (IPD) and the pattern of serotypes isolated in Navarre, Spain, after the introduction and increased coverage of the heptavalent pneumococcal conjugate vaccine (PCV7). All cases with isolation of pneumococcus from normally sterile bodily fluids were included. The incidence of IPD in children and adults was compared for the periods 2001-2002 and 2006-2007. By the end of 2002, only 11% of children aged <5 years had received any dose of PCV7, whereas, beginning in 2007, the proportion exceeded 50%. Among the cases of IPD aged <5 years, the percentage of those vaccinated increased from 7% during 2001-2002 to 53% during 2006-2007 (p <0.001). The incidence of IPD from PCV7-serotypes decreased by 85% in children <5 years (p <0.001), by 45% in the population aged 5-64 years (p 0.10) and by 68% in those >or=65 years (p 0.004). By contrast, the incidence of IPD from non-PCV7 serotypes increased by 40% overall (p 0.006). The incidence of IPD from all serotypes did not change significantly in children <5 years (from 83 to 72 per 100 000) or in the total population (from 15.8 to 16.3 per 100 000). The percentage of cases as a result of serotypes 7 and 19A increased significantly in both children and adults. No significant changes were seen in the clinical forms of IPD. The pattern of serotypes causing IPD has changed, in both children and adults, following the increased coverage of PCV7, although the incidence has been reduced only slightly.

Identification and characterization of phage variants of a strain of epidemic methicillin-resistant Staphylococcus aureus (EMRSA-15).

EMRSA-15 is one of the most important strains of epidemic methicillin-resistant Staphylococcus aureus (EMRSA) found in the United Kingdom. It was originally characterized by weak lysis with phage 75 and production of enterotoxin C but not urease. Two variant strains of EMRSA-15 which show a broader phage pattern than the progenitor strain have emerged. A total of 153 recent clinical isolates representing classical EMRSA-15 (55 isolates) or these phage variants (98 isolates) were compared by SmaI macrorestriction profiles in pulsed-field gel electrophoresis (PFGE) as well as by urease and enterotoxin C production. Eight of the 98 isolates were shown to be other unrelated strains by both PFGE and their production of urease, a misidentification rate of 8% by phage typing. Seventy-one EMRSA-15 isolates were enterotoxin C negative, and the majority of these were sensitive to phage 81. Examination of PFGE profiles and Southern blotting studies suggest that the enterotoxin C gene locus is encoded on a potentially mobile DNA segment of ca. 15 kb. After elimination of the eight non-EMRSA-15 isolates, the remaining 145 were characterized by PFGE, yielding 22 profiles. All profiles were within five band differences of at least one other profile. Classical EMRSA-15 isolates showed nine PFGE profiles, with the majority of isolates (68%) in profile B1. Six of these nine PFGE profiles were unique to the classical EMRSA-15 isolates. Among the phage variants of EMRSA-15, 16 profiles were seen, but the majority of isolates (83%) fell into 1 of 4 profiles (B2, B3, B4, and B7) which correlated well with phage patterns. The most divergent PFGE profiles among the EMRSA-15 isolates had as many as 12 band differences from one another, suggesting that in examining isolates belonging to such a temporally and geographically disseminated epidemic strain, the range of PFGE profiles must be regarded as a continuum and analyzed by relating the profiles back to the most common or progenitor profile.