[Worsening situation of tuberculosis in Chile]. / El deterioro de la tuberculosis en Chile.

BACKGROUND: Recent data suggest an increase in tuberculosis (TB) incidence in Chile. AIM: To evaluate recent epidemiological trends, geographic extension and potential factors associated with TB reemergence in Chile. MATERIAL AND METHODS: Data analysis from official sources and trend analysis. RESULTS: TB incidence rate increased from 12.3 (2014) to 14.7 (2017) per 100,000 inhabitants. Morbidity rates also increased in nine out of 15 regions. The proportion of TB cases in specific groups has also increased in the last six years: HIV/AIDS (68%), immigrants (118%), drug users/alcoholics (267%) and homeless people (370%). Several indicators of the national TB program performance have deteriorated including TB case detection, HIV co-infection study and contact tracing activities. Overall results indicate a higher than expected case-fatality ratio (> 3%), high rates of loss from follow-up (> 5%), and low percentage of cohort healing rate (< 90%). This decline is associated with a Control Program with scarce human resources whose central budget decreased by 90% from 2008 to 2014. New molecular diagnostic tools and liquid media culture were only recently implemented. CONCLUSIONS: TB trends and overall program performance indicators have deteriorated in recent years in Chile and several factors appear to be involved. Multiple strategies will be required to rectify this situation.

El deterioro de la tuberculosis en Chile / Worsening situation of tuberculosis in Chile

Background: Recent data suggest an increase in tuberculosis (TB) incidence in Chile. Aim: To evaluate recent epidemiological trends, geographic extension and potential factors associated with TB reemergence in Chile. Material and Methods: Data analysis from official sources and trend analysis. Results: TB incidence rate increased from 12.3 (2014) to 14.7 (2017) per 100,000 inhabitants. Morbidity rates also increased in nine out of 15 regions. The proportion of TB cases in specific groups has also increased in the last six years: HIV/AIDS (68%), immigrants (118%), drug users/alcoholics (267%) and homeless people (370%). Several indicators of the national TB program performance have deteriorated including TB case detection, HIV co-infection study and contact tracing activities. Overall results indicate a higher than expected case-fatality ratio (> 3%), high rates of loss from follow-up (> 5%), and low percentage of cohort healing rate (< 90%). This decline is associated with a Control Program with scarce human resources whose central budget decreased by 90% from 2008 to 2014. New molecular diagnostic tools and liquid media culture were only recently implemented. Conclusions: TB trends and overall program performance indicators have deteriorated in recent years in Chile and several factors appear to be involved. Multiple strategies will be required to rectify this situation.

Long-term impact of competitive biddings and an antimicrobial stewardship program in a general hospital in Chile / Impacto de un programa de control de antimicrobianos (PCA) y licitaciones públicas sobre el consumo de estos medicamentos

ABSTRACT Background: The long-term effect of an antimicrobial stewardship program (ASP) and its integrated impact with competitive biddings have been seldom reported. Aim: To evaluate the long-term effect of an ASP on antimicrobial consumption, expenditure, antimicrobial resistance and hospital mortality. To estimate the contribution of competitive biddings on cost-savings. Material and Methods: A comparison of periods prior (2005-2008) and posterior to ASP initiation (2009 and 2015) was done. An estimation of cost savings attributable to ASP and to competitive biddings was also performed. Results: Basal median antimicrobial consumption decreased from 221.3 to 170 daily defined doses/100 beds after the start of the ASP. At the last year, global antimicrobial consumption declined by 28%. Median antimicrobial expenditure per bed (initially US$ 13) declined to US$ 10 at the first year (-28%) and to US$ 6 the last year (-57%). As the reduction in consumption was lower than the reduction in expenditure during the last year, we assumed that only 48.4% of savings were attributable to the ASP. According to antimicrobial charges per bed from prior and after ASP implementation, we estimated global savings of US$ 393072 and US$ 190000 directly attributable to the ASP, difference explained by parallel competitive biddings. Drug resistance among nosocomial bacterial isolates did not show significant changes. Global and infectious disease-associated mortality per 1000 discharges significantly decreased during the study period (p < 0.05). Conclusions: The ASP had a favorable impact on antimicrobial consumption, savings and mortality rates but did not have effect on antimicrobial resistance in selected bacterial strains.

Antecedentes: Existe poca información sobre el impacto a largo plazo de un programa de control de antimicrobianos (PCA) y su efecto combinado con licitaciones públicas de fármacos. Objetivo: Evaluar el impacto de un PCA sobre el consumo, gasto, mortalidad y estimar la contribución de las licitaciones. Material y Métodos: Comparación antes (2005-2008) - después (2009-2015) del PCA y estimación porcentual del ahorro atribuible al PCA y licitaciones. Resultados: El consumo bajó de 221,3 a 170 dosis diarias definidas por 100 días camas (medianas) al primer año. En el último año el consumo declinó un 27,6%. La mediana del gasto por cama ocupada se redujo de 13 a 10 US$ el primer año y a 6 US$ el último año (-57%). Debido a que el gasto bajó más que el consumo, estimamos que solo el 48,4% del ahorro fue debido al PCA (cuociente de ambas reducciones: −27,6%/-57%). De acuerdo con el gasto en antimicrobianos por cama entre ambos períodos, se calculó un ahorro global de 393.000 US$ y de 190.000 US$ directamente atribuible al PCA, siendo la diferencia explicada por licitaciones. Los porcentajes de resistencia en cepas de infecciones nosocomiales no mostraron incrementos o reducciones significativas en el tiempo y la mortalidad por egresos asociada a enfermedades infecciosas (Códigos CIE 10) se redujo significativamente (p < 0,05). Conclusiones: El PCA se asoció a largo plazo a un impacto favorable sobre el consumo de antimicrobianos, gasto por antimicrobianos y egresos por enfermedades infecciosas sin un impacto en la resistencia antimicrobiana. Las licitaciones tuvieron un efecto aditivo en el ahorro.

[Exposure to risk fluids in health personnel. Evaluation of direct costs in their management]. / Exposiciones a fluidos de riesgo en el personal de salud. Evaluación de gastos directos en su manejo.

BACKGROUND: Health personnel are exposed to accidents with blood and other potentially infectious biological fluids in their clinical practice. Management of these events has high costs that are likely to be reduced. AIM: To give a general description of work accidents and their associated costs. MATERIAL AND METHOD: All healthcare workers reports of exposure to blood or risk fluids between 2010 and 2015, were included. Health care costs were calculated. Records were analyzed in a retrospective manner. RESULTS: 189 exposures to risk fluids were reported during the study period with an average of 31 accidents per year. 83.5% of the studied sources were negative for HIV, HBV and HCV, 12.6% was with unknown source and only 3.7% was positive for any of them. The costs associated with management of risk exposures was $ 2,765,890 Chilean pesos/year (4,274 USD). The average cost per event was $ 73,171 Chilean pesos (113 USD). Approximately 80% of this figure corresponds to basic management protocol. CONCLUSION: Exposure to risk fluids in health personnel is frequent and has a high cost. This cost can be reduced by the application of prevention measures to give the healthcare workers a safer environment for their daily practice.

Long-term impact of competitive biddings and an antimicrobial stewardship program in a general hospital in Chile.

BACKGROUND: The long-term effect of an antimicrobial stewardship program (ASP) and its integrated impact with competitive biddings have been seldom reported. AIM: To evaluate the long-term effect of an ASP on antimicrobial consumption, expenditure, antimicrobial resistance and hospital mortality. To estimate the contribution of competitive biddings on cost-savings. MATERIAL AND METHODS: A comparison of periods prior (2005-2008) and posterior to ASP initiation (2009 and 2015) was done. An estimation of cost savings attributable to ASP and to competitive biddings was also performed. RESULTS: Basal median antimicrobial consumption decreased from 221.3 to 170 daily defined doses/100 beds after the start of the ASP. At the last year, global antimicrobial consumption declined by 28%. Median antimicrobial expenditure per bed (initially US$ 13) declined to US$ 10 at the first year (-28%) and to US$ 6 the last year (-57%). As the reduction in consumption was lower than the reduction in expenditure during the last year, we assumed that only 48.4% of savings were attributable to the ASP. According to antimicrobial charges per bed from prior and after ASP implementation, we estimated global savings of US$ 393072 and US$ 190000 directly attributable to the ASP, difference explained by parallel competitive biddings. Drug resistance among nosocomial bacterial isolates did not show significant changes. Global and infectious disease-associated mortality per 1000 discharges significantly decreased during the study period (p < 0.05). CONCLUSIONS: The ASP had a favorable impact on antimicrobial consumption, savings and mortality rates but did not have effect on antimicrobial resistance in selected bacterial strains.

Exposiciones a fluidos de riesgo en el personal de salud. Evaluación de gastos directos en su manejo / Exposure to risk fluids in health personnel. Evaluation of direct costs in their management

Resumen Introducción: El personal de salud está expuesto a experimentar accidentes con sangre y otros fluidos biológicos potencialmente infectantes en su práctica clínica; la atención de estos eventos implica costos importantes, los que son susceptibles de reducir. Objetivo: Describir aspectos generales de los accidentes laborales y los costos asociados al manejo. Material y Método: Estudio descriptivo, retrospectivo. Se tomaron las notificaciones de exposición a fluidos en el personal de salud entre los años 2010 y 2015 y se calcularon los costos por concepto de atención de los afectados. Resultados: Se reportaron 189 exposiciones a fluido de riesgo durante el período estudiado con un promedio de 31 accidentes anuales. El 83,5% de las fuentes estudiadas fueron negativas para VIH, VHB y VHC, 12,6% fue accidente con fuente desconocida y sólo 3,7% fue positivo a alguno de estos virus. Los costos asociados al manejo de las exposiciones de riesgo fueron de $2.765.890 anuales (4,274 USD) y un costo medio de $ 73.171 por evento manejado (113 USD); cerca de 80% de esta cifra corresponde al protocolo de manejo básico. Conclusión: Las exposiciones a fluidos de riesgo en el personal de salud son frecuentes, y la atención de los afectados tiene un costo importante. Estas cifras son susceptibles de reducir en la medida que se previenen las exposiciones a fluidos, a través de las distintas estrategias validadas y al otorgar al trabajador de la salud un escenario seguro para su práctica diaria.

Background: Health personnel are exposed to accidents with blood and other potentially infectious biological fluids in their clinical practice. Management of these events has high costs that are likely to be reduced. Aim: To give a general description of work accidents and their associated costs. Material and Method: All healthcare workers reports of exposure to blood or risk fluids between 2010 and 2015, were included. Health care costs were calculated. Records were analyzed in a retrospective manner. Results: 189 exposures to risk fluids were reported during the study period with an average of 31 accidents per year. 83.5% of the studied sources were negative for HIV, HBV and HCV, 12.6% was with unknown source and only 3.7% was positive for any of them. The costs associated with management of risk exposures was $ 2,765,890 Chilean pesos/year (4,274 USD). The average cost per event was $ 73,171 Chilean pesos (113 USD). Approximately 80% of this figure corresponds to basic management protocol. Conclusion: Exposure to risk fluids in health personnel is frequent and has a high cost. This cost can be reduced by the application of prevention measures to give the healthcare workers a safer environment for their daily practice.

Costo de las neumonías asociadas a la ventilación mecánica en pacientes adultos en un hospital general en Chile / Cost evaluation of ventilator-associated pneumonia in adult patients in a general hospital in Chile

Resumen Introducción: La neumonía asociada a la ventilación mecánica (NAVM) es un evento adverso que aumenta la morbi-mortalidad y costos. Genera días adicionales de hospitalización y de procedimientos diagnósticos y terapéuticos para su tratamiento. No existen datos actualizados nacionales respecto al exceso de costos por NAVM. Objetivo: Dimensionar el costo de las NAVM en un hospital general de la Región Metropolitana. Pacientes y Métodos: Aplicación del protocolo caso-control de costos de infecciones intrahospitalarias de la Organización Panamericana de la Salud (OPS) y cálculo directo de gasto en exceso por evento de NAVM. Se comparó el exceso de días de hospitalización, de antimicrobianos en dosis diaria definida (DDD) y de cultivos. Resultados: Se recolectaron 18 casos de NAVM entre los años 2012 y 2015 en pacientes adultos. Se seleccionaron 18 controles pareados por edad y género. Se observó una mayor estadía promedio de 6,1 días en los casos (p < 0,05), una mayor prescripción de antimicrobianos (diferencia promedio de 11,7 DDD, sin significancia estadística) y un exceso de solicitud de cultivos con una diferencia promedio de 3,2 (p < 0,05). El costo unitario por NAVM fue de 4.475 USD. Conclusiones: Los eventos de NAVM generan una mayor estadía hospitalaria, consumo de recursos diagnósticos y terapéuticos.

Background: Ventilator-associated pneumonia (VAP) is an adverse event that increases morbidity, mortality and costs due to a prolonged stay and requirement of microbiological studies and antimicrobial therapy. There is not recent data of VAP costs in Chile. Aim: To evaluate additional costs in adult patients with VAP compared to controls in a general hospital in the Metropolitan Area. Patients and Methods: Use of the PAHO paired casecontrol protocol for cost evaluation associated to nosocomial infections and estimation of cost in excess per VAP event. Length of stay (LOS) in excess, antimicrobial consumption in daily-defined doses (DDD), and number of microbiological studies were compared between both groups. Results: From 2012 to 2015, 18 patients with VAP events were identified with their respective controls. LOS exceeded 6.1 days on average among patients with VAP respect to controls (p < 0.05). DDD was higher among patients with VAP (difference 11.7 DDD) as well as number of cultures (3.2 higher on average, p < 0.05). Cost in excess per VAP event reached 4,475 USD. Conclusions: In our Centre, VAP events are associated to a higher LOS, antimicrobial consumption and microbiological studies.

[Cost evaluation of ventilator-associated pneumonia in adult patients in a general hospital in Chile]. / Costo de las neumonías asociadas a la ventilación mecánica en pacientes adultos en un hospital general en Chile.

BACKGROUND: Ventilator-associated pneumonia (VAP) is an adverse event that increases morbidity, mortality and costs due to a prolonged stay and requirement of microbiological studies and antimicrobial therapy. There is not recent data of VAP costs in Chile. AIM: To evaluate additional costs in adult patients with VAP compared to controls in a general hospital in the Metropolitan Area. PATIENTS AND METHODS: Use of the PAHO paired casecontrol protocol for cost evaluation associated to nosocomial infections and estimation of cost in excess per VAP event. Length of stay (LOS) in excess, antimicrobial consumption in daily-defined doses (DDD), and number of microbiological studies were compared between both groups. RESULTS: From 2012 to 2015, 18 patients with VAP events were identified with their respective controls. LOS exceeded 6.1 days on average among patients with VAP respect to controls (p < 0.05). DDD was higher among patients with VAP (difference 11.7 DDD) as well as number of cultures (3.2 higher on average, p < 0.05). Cost in excess per VAP event reached 4,475 USD. CONCLUSIONS: In our Centre, VAP events are associated to a higher LOS, antimicrobial consumption and microbiological studies.

[Gastos hospitalarios por neumonía neumocóccica invasora en adultos en un hospital general en Chile]. / Hospital charges by bacteremic pneumococcal pneumonia in adults in a general hospital.

Pneumococcal infections are important for their morbidity and economic burden, but there is no economical data from adults patients in Chile. AIMS: Estimate direct medical costs of bacteremic pneumococcal pneumonia among adult patients hospitalized in a general hospital and to evaluate the sensitivity of ICD 10 discharge codes to capture infections from this pathogen. METHODS: Analysis of hospital charges by components in a group of patients admitted for bacteremic pneumococcal pneumonia, correction of values by inflation and conversion from CLP to US$. RESULTS: Data were collected from 59 patients admitted during 2005-2010, mean age 71.9 years. Average hospital charges for those managed in general wards reached 2,756 US$, 8,978 US$ for those managed in critical care units (CCU) and 6,025 for the whole group. Charges were higher in CCU (p < 0.001), and patients managed in these units generated 78.3% of the whole cost (n = 31; 52.5% from total). The median cost in general wards was 1,558 US$, and 3,993 in CCU. Main components were bed occupancy (37.8% of charges), and medications (27.4%). There were no differences associated to age, comorbidities, severity scores or mortality. No single ICD discharge code involved a S. pneumoniae bacteremic case (0% sensitivity) and only 2 cases were coded as pneumococcal pneumonia (3.4%). CONCLUSIONS: Mean hospital charges (~6,000 US dollars) or median values (~2,400 US dollars) were high, underlying the economic impact of this condition. Costs were higher among patients managed in CCU. Recognition of bacteremic pneumococcal infections by ICD 10 discharge codes has a very low sensitivity.

Gastos hospitalarios por neumonía neumocóccica invasora en adultos en un hospital general en Chile / Hospital charges by bacteremic pneumococcal pneumonia in adults in a general hospital

Pneumococcal infections are important for their morbidity and economic burden, but there is no economical data from adults patients in Chile. Aims. Estimate direct medical costs of bacteremic pneumococcal pneumonia among adult patients hospitalized in a general hospital and to evaluate the sensitivity of ICD 10 discharge codes to capture infections from this pathogen. Methods. Analysis of hospital charges by components in a group of patients admitted for bacteremic pneumococcal pneumonia, correction of values by inflation and conversion from CLP to US$. Results. Data were collected from 59 patients admitted during 2005-2010, mean age 71.9 years. Average hospital charges for those managed in general wards reached 2,756 US$, 8,978 US$ for those managed in critical care units (CCU) and 6,025 for the whole group. Charges were higher in CCU (p < 0.001), and patients managed in these units generated 78.3% of the whole cost (n = 31; 52.5% from total). The median cost in general wards was 1,558 US$, and 3,993 in CCU. Main components were bed occupancy (37.8% of charges), and medications (27.4%). There were no differences associated to age, comorbidities, severity scores or mortality. No single ICD discharge code involved a S. pneumoniae bacteremic case (0% sensitivity) and only 2 cases were coded as pneumococcal pneumonia (3.4%). Conclusions. Mean hospital charges (~6,000 US dollars) or median values (~2,400 US dollars) were high, underlying the economic impact of this condition. Costs were higher among patients managed in CCU. Recognition of bacteremic pneumococcal infections by ICD 10 discharge codes has a very low sensitivity.

Las infecciones neumocócicas representan una gran carga de morbilidad y de gastos en salud en pacientes adultos pero no se dispone de datos que hayan evaluado su dimensión económica en Chile. Objetivo: Evaluar los gastos directos en un grupo de pacientes adultos hospitalizados por neumonía neumocóccica bacterémica en un hospital general y evaluar la sensibilidad de los códigos de egreso CIE 10 para capturar las infecciones por este patógeno. Métodos: Análisis de gastos por componentes de un grupo de pacientes atendidos por neumonía neumocóccica bacteriémica, actualización de gastos y conversión a US$. Resultados: Se rescató información de 59 pacientes atendidos entre el 2005-2010, con edad promedio de 71,9 años. El gasto promedio en sala fue de 2.756 US$, de 8.978 US$ en Unidades Críticas y de 6.025 US$ para el grupo total. Los gastos fueron mayores en Unidades Críticas (p < 0,001) y los pacientes en estas unidades (n = 31; 52,5% del total) generaron el 78,3% del gasto total observado. La mediana de gastos en sala fue de 1.558 US$ y de 3.993 US$ en el caso de Unidades Críticas. El 37,8% del gasto se originó por día-cama y 27,4% por medicamentos. No hubo diferencias por edad, co-morbilidades, scores de gravedad o mortalidad. Ningún código CIE 10 involucró bacteriemia por S. pneumoniae (Sensibilidad 0%) y sólo 2 casos fueron codificados como neumonía neumocóccica (3,4%). Conclusiones: El gasto promedio (aprox. 6.000 dólares americanos) y mediana (aprox. 2.400 dólares americanos) fueron elevados evidenciando la importancia económica de esta enfermedad. Los gastos fueron mayores en pacientes manejados en Unidades Críticas. La sensibilidad de los códigos CIE 10 fue baja para reconocer eventos de ENI en esta serie.

Cotrimoxazol en infecciones óseas: toxicidad e impacto clínico y económico / Cotrimoxazole in bone-related infections: toxicity and clinical and economic impact

Background: Cotrimoxazole is a therapeutic option for bone-related infections but is associated to hyperkalemia and renal failure. Tolerance to this drug may reduce length of stay (LOS) and hospital charges. Aims: To evaluate renal, potassium toxicity, clinical outcome, and use of hospital resources in patients treated with cotrimoxazole for bone-related infections. Methods: Retrospective analysis of adult patients with bone-related infections confirmed by culture and treated with this drug. Serum potassium and creatinine levels were analyzed during follow-up and risk factors for hyperkalemia were searched. Length of stay (LOS) and hospital charges were compared. Clinical outcome was evaluated as a secondary endpoint. Results: From 2011 to 2014, 23 patients were identified (mean age 64.7 years). Diabetes mellitus, peripheral vascular disease, and previous amputations prevalence were high (82.6%, 47.8%, and 43.5%, respectively). Median serum potassium concentration increased significantly at first control (4.35 mEq/L to 4.9 mEq/L; p < 0.001), and also creatinine serum concentration (0.9 to 1.1 mg/dL; p < 0.05). Seven patients developed hyperkalemia. Cotrimoxazole was discontinued in 10 patients (43.5%), and in 6, discharge was postponed. Drugs active against the renin-angiotensin system (DAARAS) were associated with kyperkalemia (OR 10.8 IC95 1.37-85; p < 0.05). LOS was higher among patients with cotrimoxazole toxicity (median LOS 56 versus 30 days, p < 0.05). Patients with no cotrimoxazole interruption had less drug-related hospital charges (median values of 563 versus 2820 USD, respectively; p < 0.01). Conclusions: Cotrimoxazole use must be monitored in order to detect hyperkalemia or renal toxicity and suspend its prescription. Patients that use DAARAS have a higher risk of kyperkalemia. LOS and drug-related hospital charges are reduced when patients can tolerate cotrimoxazole.

Antecedentes: Cotrimoxazol es una alternativa en infecciones óseas pero se ha asociado al desarrollo de falla renal e hiperkalemia. Objetivo: Evaluar toxicidad renal, hiperkalemia, estadía y gastos hospitalarios y evolución clínica en un grupo de pacientes con infecciones óseas tratados con este compuesto. Pacientes y Métodos: Estudio retrospectivo-descriptivo de pacientes adultos con infecciones óseas confirmadas con cultivos y tratados con este compuesto. Seguimiento de creatinina y kalemia y búsqueda de factores de riesgo para hiperkalemia, comparación de gastos y estadía hospitalaria y análisis de eficacia clínica. Resultados: Desde el año 2011 al 2014 se identificaron 23 pacientes (promedio de edad 64,7 años). La prevalencia de diabetes mellitus tipo 2 (82,6%), enfermedad vascular periférica (47,8%) y amputaciones previas (43,5%) fue elevada. La mediana de la kalemia basal aumentó significativamente al primer control (4,35 a 4,9 mEq/L) al igual que la creatinina plasmática (0,9 a 1,1 mg/dL). Siete pacientes desarrollaron hiperkalemia (30,4%). Se suspendió cotrimoxazol en 10 casos (43,5%) y en 6 casos se postergó el alta. El uso de fármacos activos contra el sistema renina-angiotensina (FASRA) se asoció a hiperkalemia (OR 10,8 IC95 1,37-85; p < 0,05). La estadía hospitalaria fue mayor en el grupo con toxicidad a cotrimoxazol (mediana de 56 versus 30 días; p < 0,05) y los pacientes sin suspensión de terapia tuvieron menos gastos por fármacos (medianas de 563 vs 2.820 USD, p < 0,01). Conclusiones: El uso de cotrimoxazol debe ser monitorizado para detectar hiperkalemia o toxicidad renal y suspender su prescripción. Los pacientes que usan FASRA tienen mayor riesgo de hiperkalemia. La estadía y gastos hospitalarios por fármacos son menores en pacientes que toleran el cotrimoxazol.

[Cotrimoxazole in bone-related infections: toxicity and clinical and economic impact]. / Cotrimoxazol en infecciones óseas: toxicidad e impacto clínico y económico.

BACKGROUND: Cotrimoxazole is a therapeutic option for bone-related infections but is associated to hyperkalemia and renal failure. Tolerance to this drug may reduce length of stay (LOS) and hospital charges. AIMS: To evaluate renal, potassium toxicity, clinical outcome, and use of hospital resources in patients treated with cotrimoxazole for bone-related infections. METHODS: Retrospective analysis of adult patients with bone-related infections confirmed by culture and treated with this drug. Serum potassium and creatinine levels were analyzed during follow-up and risk factors for hyperkalemia were searched. Length of stay (LOS) and hospital charges were compared. Clinical outcome was evaluated as a secondary endpoint. RESULTS: From 2011 to 2014, 23 patients were identified (mean age 64.7 years). Diabetes mellitus, peripheral vascular disease, and previous amputations prevalence were high (82.6%, 47.8%, and 43.5%, respectively). Median serum potassium concentration increased significantly at first control (4.35 mEq/L to 4.9 mEq/L; p < 0.001), and also creatinine serum concentration (0.9 to 1.1 mg/dL; p < 0.05). Seven patients developed hyperkalemia. Cotrimoxazole was discontinued in 10 patients (43.5%), and in 6, discharge was postponed. Drugs active against the renin-angiotensin system (DAARAS) were associated with kyperkalemia (OR 10.8 IC95 1.37-85; p < 0.05). LOS was higher among patients with cotrimoxazole toxicity (median LOS 56 versus 30 days, p < 0.05). Patients with no cotrimoxazole interruption had less drug-related hospital charges (median values of 563 versus 2820 USD, respectively; p < 0.01). CONCLUSIONS: Cotrimoxazole use must be monitored in order to detect hyperkalemia or renal toxicity and suspend its prescription. Patients that use DAARAS have a higher risk of kyperkalemia. LOS and drug-related hospital charges are reduced when patients can tolerate cotrimoxazole.

[Cost evaluation of catheter-related bloodstream infections in adult patients in Chile]. / Estudio de costo de las infecciones del torrente sanguíneo asociadas a catéter vascular central en pacientes adultos en Chile.

BACKGROUND: Nosocomial infections are common adverse events associated with increased morbidity, mortality, and costs of patient care. Catheter-related bloodstream infections (CR-BSI) are nosocomial infections associated with higher medical costs. AIMS: To evaluate CR-BSI associated costs in the Hospital Militar of Santiago, Chile, during year 2013. METHODS: Comparative study between cases (CR-BSI) and matched controls using the Pan American Health Organization protocol. Variables were excess in length of stay (LOS), antimicrobial use according to daily defined doses (DDD), and total number of microbial cultures per hospitalization which were compared with non-parametric tests. RESULTS: We included 10 cases and 10 matched controls. Mean LOS among cases was 40 days vs. 20.3 among controls (excess 20.3 days per event; p < 0.05). Antimicrobial consumption was higher among cases (DDD 36 vs. 10.5; p < 0.05) and there was a trend to an increased number of bacterial cultures among cases (9 vs. 5; p = 0.057). The additional cost for the 10 subjects was 38 Chilean million pesos (USD 72,869) with a mean of 7,286 USD per event. CONCLUSIONS: During one year, CR-BSI generated an excess in LOS, antimicrobial consumption, and costs (7,286 USD per event of CR-BSI).

[Hospital care expenses caused by acute fascioliasis, cystic echinococcosis, and neurocysticercosis in Santiago, Chile]. / Gastos hospitalarios en pacientes con fascioliasis en fase aguda, hidatidosis de tratamiento quirúrgico y neurocisticercosis en un hospital general en Chile.

BACKGROUND: Acute fascioliasis (FA), cystic echinococcosis (CE) and neurocysticercosis (NCC) are three endemic parasitic diseases in Chile for whom there is scarce information about the economic impact they represent during management at the hospital. AIMS: To quantify and compare hospital care expenses caused by these three endemic helminth infections in a Chilean hospital. METHODS: Retrospective analysis of hospital costs at a referral hospital in Santiago between 2006 and 2010. Hospital databases were used to identify patients with the corresponding infections, and those with sufficient data on hospital costs were included. RESULTS: A total of 16 patients representing 21 cases were identified and analyzed: four with AF, eleven with CE, and six with NCC. Median hospital expenses for cases with AF were US$ 1799 and mainly caused by bed-day costs. Median hospital costs for cases of CE were US$ 4707 and the most important costs components were medications, bed-day costs and consumables. NCC patients had median costs of US$ 1293, which were mainly due to bed-day costs. Non-parenchymatous or mixed forms of NCC showed a trend toward higher hospital costs compared with parenchymatous forms. CONCLUSIONS: Although helminth infections in Chile, an upper middle income country, are declining and considered rare in routine clinical practice, hospital care expenses caused by patients with AF, CE, and NCC are high and might still present an important economic burden to the Chilean healthcare system.

Gastos hospitalarios en pacientes con fascioliasis en fase aguda, hidatidosis de tratamiento quirúrgico y neurocisticercosis en un hospital general en Chile / Hospital care expenses caused by acute fascioliasis, cystic echinococcosis, and neurocysticercosis in Santiago, Chile

Background: Acute fascioliasis (FA), cystic echinococcosis (CE) and neurocysticercosis (NCC) are three endemic parasitic diseases in Chile for whom there is scarce information about the economic impact they represent during management at the hospital. Aims: To quantify and compare hospital care expenses caused by these three endemic helminth infections in a Chilean hospital. Methods: Retrospective analysis of hospital costs at a referral hospital in Santiago between 2006 and 2010. Hospital databases were used to identify patients with the corresponding infections, and those with sufficient data on hospital costs were included. Results: A total of 16 patients representing 21 cases were identified and analyzed: four with AF, eleven with CE, and six with NCC. Median hospital expenses for cases with AF were US$ 1799 and mainly caused by bed-day costs. Median hospital costs for cases of CE were US$ 4707 and the most important costs components were medications, bed-day costs and consumables. NCC patients had median costs of US$ 1293, which were mainly due to bed-day costs. Non-parenchymatous or mixed forms of NCC showed a trend toward higher hospital costs compared with parenchymatous forms. Conclusions: Although helminth infections in Chile, an upper middle income country, are declining and considered rare in routine clinical practice, hospital care expenses caused by patients with AF, CE, and NCC are high and might still present an important economic burden to the Chilean healthcare system.

Antecedentes: La fascioliasis aguda (FA), la equinococosis o hidatidosis (H) y la neurocisticercosis (NCC) son tres enfermedades parasitarias endémicas en Chile de las cuales hay escasa información sobre el impacto económico que ellas generan por atención hospitalaria. Objetivos: Cuantificar y comparar los gastos hospitalarios causados por estas tres infecciones por helmintos en un hospital en Chile. Materiales y Métodos: Análisis retrospectivo de gastos hospitalarios en un hospital de referencia en Santiago entre los años 2006 y 2010. Se incluyeron aquellos casos identificados en las bases de datos de hospital y que contaran con datos económicos suficientes. Resultados: Un total de 16 pacientes con 21 ingresos fue identificado y analizado: 4 con FA, 11 con H y 6 con NCC. La mediana de gastos hospitalarios para los ingresos por FA fue de US$ 1.799, originados fundamentalmente por el costo del día cama. La mediana de los gastos en ingresos por H fue de US$ 4.707 y los componentes más importantes en el gasto fueron los medicamentos, estadía hospitalaria e insumos. Los pacientes con NCC tuvieron una mediana de gastos de US$ 1.293 explicado principalmente por la estadía hospitalaria. Los pacientes con formas no parenquimatosas o mixtas tuvieron una tendencia a presentar gastos más altos que aquellos con formas parenquimatosas de NCC. Conclusiones: Aunque las infecciones por helmintos están en declinación en Chile, un país de ingresos medios, y son consideradas raras en la práctica clínica, los gastos hospitalarios generados por la atención de pacientes con FA, H y NCC, son elevados y aún representan una importante carga económica para el sistema de salud chileno.

[Cancer of cervix in Chile. Too much vaccine amid a neglected Papanicolau]. / Prevención del cáncer cérvico-uterino en Chile. Mucha vacuna y poco Papanicolau.

The Chilean Ministry of Health announced the incorporation of a human papillomavirus (HPV) vaccine to prevent cervix uterine cancer (CUC) into the national immunization program during year 2014 This decision was adopted despite of two opposing documents and a significant decrease in cervical cancer associated mortality due to cytological cervical screening. The burden of disease attributed to CUC has declined in Chile and current cost-effectiveness studies should be reviewed considering this decreasing trend, the progressive decrease in coverage rates observed during the past years, the potential need for aditional doses and lower vaccine costs if vaccine is acquired through the PAHO revolving fund. Moreover, serious adverse events associated with these vaccines, which in some countries are more frequent than CUC associated mortality, have not been thoroughly evaluated and are probably underreported. The decision to incorporate the vaccine occurs in a context of progressive weakening of the national cervical screening program leading to a reduced population coverage. This situation jepeordizes the achievements already obtained and poses a challenge to vaccine introduction considering that not all the high-risk viral subtypes are included and thus the risk for CUC does not disappear making cervical screening a vital component of the program that needs to be maintained. This governmental resolution requires a more solid scientific foundation and should not be implemented without resolving current cervical screening shortcomings.

Morbilidad y mortalidad asociada a hospitalizaciones por influenza pandémica A (H1N1) 2009 en dos hospitales de la Región Metropolitana y evaluación de su impacto económico / Morbidity and mortality associated to influenza A (H1N1) 2009 admissions in two hospitals of the Metropolitan area and analysis of its economic impact

Influenza A (H1N1) 2009 infection was an important cause of morbidity and mortality in Chile. Aim: To characterize the clinical pattern of hospitalized patients, identify risk factors associated with ICU admission or death, and evaluate its economic impact. Patients and Methods: Twenty five adult patients admitted to 2 hospitals in the Metropolitan Area from May 2009 to December 2010 with PCR confirmed H1N1 infection were analyzed. Total hospital charges were obtained and, using data of registered cases, expenses for the whole country during the first epidemic wave were estimated. Results: Aill cases presented a risk factor: age over 60 years old (n = 13, 52%), co-morbid conditions (n = 24, 96%) or pregnancy (n = 1, 4%). Pneumonia was present in 64% (n = 16) and 16% (n = 4) had hypotension. Only 6 patients (24%) had a CURB-65 score ≥ 2 and 36% (n = 9) requiring ICU admission. Case fatality rate was 16% (n = 4). By multivariate analysis, diabetes mellitus type 2 was independently associated with ICU admission or death (OR 8.12; IC95 1.11-59.2, p < 0.05). Hospital charges for those admitted to ICU or the intermediate care unit reached US$ 20,304, and US$ 1,262 for those admitted in general wards. We estimated US$ 20 million in hospital charges for influenza related hospitalizations during the first wave for the whole country. Conclusions: A high proportion of patients affected by influenza A (H1N1) 2009 infection required ICU admission during 2009-2010. Case fatality rate associated to this infection was high, and diabetes mellitus type 2 was a risk factor for ICU admission or death. Hospital charges were higher for those admitted in critical care units and represented an important expenditure for Chile during the first wave. The CURB-65 score was inappropriate to recognize patients at risk of hospitalization or ICU admission.

Introducción: La infección por influenza A (H1N1) pandémica representó una importante carga de morbilidad y mortalidad en Chile. Objetivo: Caracterización clínica de pacientes hospitalizados durante los años 2009 y 2010, identificar factores de riesgo asociados con ingreso a UCI o muerte y determinar el impacto económico de esta enfermedad. Pacientes y Métodos: Análisis de las características clínicas y evolución en un grupo de 25 pacientes adultos ingresados a dos hospitales institucionales en la Región Metropolitana confirmados por RPC desde mayo de 2009 a diciembre de 2010. Estudio de gastos hospitalarios y estimación de gasto nacional según registro de casos atendidos desde mayo a agosto de 2009. Resultados. Todos los pacientes presentaron una condición de riesgo: edad > 60 años (n: 13, 52%), co-morbilidad (n: 24, 96%) o embarazo ((n: 1, 4%). El 64% (n: 16) presentó neumonía y 16% tuvieron hipotensión arterial (n: 4). Sólo 6 pacientes (24%) tuvieron puntuación CURB-65 ≥ 2. Un 36% (n: 9) requirió manejo en Unidad de Cuidados Intensivos (UCI) y 4 pacientes fallecieron (16%). Por análisis multivariado, el antecedente de diabetes mellitus tipo 2 se asoció en forma significativa e independiente al ingreso a UCI o a un desenlace fatal (OR 8,12; IC95 1,11-59,2, p < 0,05). El gasto por paciente en aquellos que ingresaron a la UCI o Intermedio alcanzó los US$ 20.304 y US$ 1.262, para los que no ingresaron a estas unidades. Para Chile, se estimó un gasto mínimo de 20 millones de dólares por concepto de hospitalización para los primeros cuatro meses de la pandemia el 2009, asumiendo que 60% ingresó a UCI o Unidades Intermedias. Conclusiones: Una alta proporción de los pacientes afectados por influenza A (H1N1) 2009 requirió ingreso a UCI durante los años 2009-2010. La letalidad de esta infección fue elevada y la diabetes mellitus tipo 2 fue un factor de riesgo para ingreso a UCI o muerte. Los gastos hospitalarios fueron elevados, especialmente en los que ingresaron a unidades críticas. El sistema CURB-65 tiene una baja capacidad para reconocer riesgo de hospitalización o muerte en estos pacientes.

[Morbidity and mortality associated to influenza A (H1N1) 2009 admissions in two hospitals of the Metropolitan area and analysis of its economic impact]. / Morbilidad y mortalidad asociada a hospitalizaciones por influenza pandémica A (H1N1) 2009 en dos hospitales de la Región Metropolitana y evaluación de su impacto económico.

UNLABELLED: Influenza A (H1N1) 2009 infection was an important cause of morbidity and mortality in Chile. AIM: To characterize the clinical pattern of hospitalized patients, identify risk factors associated with ICU admission or death, and evaluate its economic impact. PATIENTS AND METHODS: Twenty five adult patients admitted to 2 hospitals in the Metropolitan Area from May 2009 to December 2010 with PCR confirmed H1N1 infection were analyzed. Total hospital charges were obtained and, using data of registered cases, expenses for the whole country during the first epidemic wave were estimated. RESULTS: Aill cases presented a risk factor: age over 60 years old (n = 13, 52%), co-morbid conditions (n = 24, 96%) or pregnancy (n = 1, 4%). Pneumonia was present in 64% (n = 16) and 16% (n = 4) had hypotension. Only 6 patients (24%) had a CURB-65 score ≥ 2 and 36% (n = 9) requiring ICU admission. Case fatality rate was 16% (n = 4). By multivariate analysis, diabetes mellitus type 2 was independently associated with ICU admission or death (OR 8.12; IC95 1.11-59.2, p < 0.05). Hospital charges for those admitted to ICU or the intermediate care unit reached US$ 20,304, and US$ 1,262 for those admitted in general wards. We estimated US$ 20 million in hospital charges for influenza related hospitalizations during the first wave for the whole country. CONCLUSIONS: A high proportion of patients affected by influenza A (H1N1) 2009 infection required ICU admission during 2009-2010. Case fatality rate associated to this infection was high, and diabetes mellitus type 2 was a risk factor for ICU admission or death. Hospital charges were higher for those admitted in critical care units and represented an important expenditure for Chile during the first wave. The CURB-65 score was inappropriate to recognize patients at risk of hospitalization or ICU admission.