[Antibiotic multiresistance in critical care units]. / Multirresistencia antibiótica en unidades de críticos.

The presence of microorganisms with acquired resistance to multiple antibiotics complicates the management and outcome of critically ill patients. The intensivist, in his/her daily activity, is responsible for the prevention and control of the multiresistance and the challenge of prescribing the appropriate treatment in case of an infection by these microorganisms. We have reviewed the literature regarding the definition, important concepts related to transmission, recommendations on general measures of control in the units and treatment options. We also present data on the situation in our country known primarily through the ENVIN-UCI register. Addressing the multiresistance not only requires training but also teamwork with other specialists and adaptation to the local environment.

Antiseptic urinary catheterization and maintenance of the bladder catheter. / Antisepsia en el sondaje urinario y en el mantenimiento de la sonda vesical.

Catheter-related urinary tract infections are very common both in the community and in the acute hospital care setting, particularly in the critical care environment. In order to minimize this problem, it is essential to adopt a correct approach from insertion to withdrawal of the urinary catheter, and always perform proper antisepsis. There is too much information on antisepsis measures with no consistent results. The present article reviews the existing scientific evidence on the subject and establishes recommendations based on the evidence, in order to optimize outcomes. The entire process is complemented with considerations on how to secure proper management of the indwelling urinary catheter. This article is part of a supplement entitled "Antisepsis in the critical patient", which is sponsored by Becton Dickinson.

[New therapeutic options for the treatment of multiresistant bacteria in the ICU]. / Nuevas opciones terapéuticas para el tratamiento de las bacterias multirresistentes en Unidades de Cuidados Intensivos.

The number of new antimicrobial drugs in the health care clinical practice has decreased gradually and significantly in the last 15 years. At the same time, there has been an increase in the appearance of microorganisms with resistance to conventional antibiotics, above all in intensive care units (ICU). Within this group, Methicillin-resistant Staphylococcus aureus (MSRA) and methicillin-resistant coagulase- negative staphylococci, vancomycin-resistant enterococci, Pseudomonas aeruginosa and Acinetobacter baumanii resistant to carbapenemics and extended-spectrum betalactamase-producing (ESBL) Enterobacteria are the most important. These pathogens are frequently also resistant to other groups of antibiotics such as aminoglycosides, fluoroquinolones and macrolides. New recently introduced antimicrobial agents are available to combat these resistances. These are active mainly against gram positive bacteria resistant strains and in a more timely way against gram negative ones or both. Among the first group, the following stand out: daptomycin (a lipopeptide bactericide for parenteral use) and linezolid (oxazolidinone with bacteriostatic activity for parenteral and oral use). On its part, ertapenem (a carbapenem parenteral bactericide) and tigecyclin (a parenteral bacteriostatic tetracycline) are active against ESBL enterobacteria, the latter also being active against non-fermented gram positives and gram negatives, except for P. aeruginosa. Possibly, the introduction of these new compounds and other futures ones pending introduction will not only improve antimicrobial diversification but also serve to limit the spreading of these microorganisms.

[Hand hygiene: scientific evidence and common sense]. / Higiene de las manos: evidencia científica y sentido común.

Hand washing was rightly considered a measure of personal hygiene for centuries. Today there is enough scientific evidence showing that a simple and inexpensive measure can help significantly reduce clinical infections. In spite of this, published studies show that hand hygiene only takes place between 15% and 50% of the instances in which it should be done. In order to support countries in setting priorities to deal with infections related to health care, the World Health Organization has developed a campaign to improve compliance with hand hygiene. Fundamental elements of the campaign include staff training, change of habits, motivating health professionals, and enabling access to effective products at the point of patient care. At institutional level, healthcare managers need to make a firm commitment, and make hand hygiene one of the quality assurance objectives of their organisations.

[Total prosthetic knee and hip joint infection. Descriptive epidemiology, therapeutics and evolution in a secondary hospital during ten years]. / Infección de prótesis total de rodilla y cadera. Epidemiología descriptiva, terapéutica y evolución en un hospital de segundo nivel durante 10 años.

OBJECTIVE: Epidemiological description, retrospective in its classification, evolution and therapeutics of total prosthesis knee and hip infected among the arthoplasties made between 1st of January 1994 and 31st of December 2003 in our hospital. RESULTS: The global infection rate was 2.4% (confidence interval of 95% [CI 95%], 1.6%-3.2%) over 40 cases in 1,666 joint implants. The average age +/- standard deviation (SD) was 69.5 years old +/- 5.1 years, mainly in women (67.5%). The most common location was the knee, 31 cases (77.5%). In 90.0% of the patients the aetiology was identified: 64,0% were gram-positive cocci (plasmacoagulase-negative staphylococci, and Staphylococcus aureus); 14.0% were gram-negative bacilli and mixed flora (11.0%). Acute infections were found in most of the cases (45,0%). The joint replacement had a healing rate of 66.7% in the first replacement and of 83.3% in the second replacement. CONCLUSIONS: The gram-positive cocci are the main microorganisms in these infections. More extensive studies about multiple aspects are necessary to evaluate the effectiveness of the different surgical techniques, the new antibiotics and the combined antibiotic therapies.

[Nosocomial infection by multiresistant pathogens during one year in a secondary hospital: clinical an epidemiological analysis]. / Infección nosocomial por gérmenes multirresistentes durante 1 año en un hospital de segundo nivel: análisis clínico y microbiológico.

BACKGROUND: Currently growing medical and social significance of nosocomial infection by multiresistant pathogens (NIMP) prompted us to establish its incidence, nosology, presenting forms in admission areas, and mortality in a secondary hospital, Lleida (Spain). METHOD: For that purpose, we analyzed the first year experience of a unit for the control of nosocomial infection (NI) created in our hospital. From January to December 2000, 79 patients with a NIMP admitted to the University Hospital Arnau de Vilanova entered in this prospective, descriptive study. RESULTS: The overall annual incidence of NIMP was 4.0 per 103 patients admitted. Acinetobacter baumannii showed the highest individual rate of incidence, particularly, at the Intensive Care Unit (15.4 per 103 patients admitted; p < 0.001). By nosologies, infection prevailed over colonization (69.6% vs 30.4%; p < 0.001). Mean hospital stay length increased in colonized patients (38.9 days). Finally, overall mortality was high (29.1%); again, A. baumannii was the agent most frequently detected in death cases (66.6%; p < 0.001). CONCLUSIONS: Surveillance and control measures are required for the prevention of NIMP. Incidence studies how this, can be useful to create a database to establish the distribution and occurrence of NI, including the detection of multiresistant pathogen outbreaks.

[Use of antibiotics for the treatment of multiresistant gram positive cocci infections in critical patients]. / Utilización de antibióticos en el tratamiento de infecciones por cocos grampositivos multirresistentes en pacientes críticos.

INTRODUCTION: This study has been designed to know the use of these antibiotics (ATB) in Intensive Care Units (ICUs). DESIGN AND PATIENTS: A multicentric, prospective, observational study was conducted. In cluded as cases were the indications of vancomycin (VAN), teicoplanin (TPN), quinupristin/dalfopristin (Q/D) and linezolid (LZD). RESULTS: A total of 826 indications (VAN 52.1%, TPN 36.6%, LZD 11.6% and Q/D 0%) were analyzed, 793 (96%) as treatment and 33 (4%) as prophylaxis in 818 patients. Serious sepsis or septic should occurred in 55.9% of the patients treated. The most common infections were pneumonia and catheter-related bacteremia, 48.3% of all the infections being acquired in ICUs. LZD was used mostly in mechanical-ventilation related pneumonia (p = 0.001), VAN in community Central Nervous System infections (p = 0.01) and in catheter-related bacteremia (p = 0.001), TPN in community pneumonia (p = 0.01) and in catheter-related bacteremia (p = 0.001). Treatments were empirical in 65.8% and diagnosis of gram positive cocci was confirmed in 48.3% of them. Staphylococcus aureus was isolated more in the LZD-treated group. Initial treatment was modified 224 times, this occurring more frequently in the VAN-treated group. The reason for this change was clinical failure 59 times, this being more frequent in the TPN group and less frequent in the patients treated with LZD, which was the drug used the most in rescue therapies (43/69, 62.3%). Adverse events, probably related to the ATB, were identified in 36/826 (4.4%) cases. CONCLUSIONS: The most common use of this ATB was to treat ICU-acquired infections. VAN was the most frequently used drug. Treatments with LZD were modified less frequently for clinical failure and this drug was the one most used in rescue therapies. This information indicates an appropriate use of these ATB in an important percentage of critically patients.

[Recommendations for the treatment of severe in-hospital pneumonia. Spanish Society of Critical, Coronary, and Intensive Medicine. Spanish Society for Respiratory Tract Pathology. Spanish Society of Infectious Diseases and Clinical Microbiology]. / Recomendaciones para el tratamiento de la neumonía intrahospitalaria grave. Sociedad Española de Medicina Intensiva, Critica y Coronarias. Sociedad Española de Patología del Aparato Respiratorio. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica.

INTRODUCTION: Given the sanitary repercussion of serious intrahospital pneumonia (SIP), representatives of three scientific societies (SEMICYUC; SEPAR and SEIMC) have developed during 2002 and 2003 a practical guide for its treatment. METHOD: A task force was constituted to value five clinical situations related with the treatment of SIP: 1) critical revision of the existent guidelines and groups of risk definition; 2) entry criteria in ICU for SIP; 3) SIP treatment in function of the groups of risk; 4) special situations in SIP treatment, and 5) control treatment. After the bibliographical revision drafts were developed and discussed until the elaboration of the final document. RESULTS: It is necessary the stratification of the patients according to the presence or not of risk factors in order to make an appropriate use of treatments. SIP without risk factors can be treated with monotherapy with several antibiotics. SIP with risk factors specifies therapy combined with betalactamic plus aminoglycoside. Its substitution for a quinolon is a topic debate. Infections for multiresistance microorganisms require an individualized approach that can end up including the use of topical antibiotics. In SIP without microorganism isolation the use of a score system can be of utility in the taking of decisions. Revision of the therapeutic rule after 72 hours, carrying out the necessary adjustments according to the clinical evolution and microbiological results is necessary in all cases. CONCLUSIONS: Scientific evidence in the treatment of SIP allows the development of different strategies to achieve a higher efficiency both in antibiotic handling and in the control of its evolution.