RESUMO
OBJECTIVES: To evaluate the effectiveness of empirical therapy with ß-lactam/ß-lactamase inhibitor combinations (BL/BLICs) for MSSA bacteraemia. METHODS: We conducted a post hoc analysis of all adult patients with MSSA bacteraemia who were hospitalized at a Spanish university hospital between 2013 and 2018. We compared 30â day mortality among patients receiving initial therapy with BL/BLICs (de-escalated to cloxacillin or cefazolin within 96â h) versus cloxacillin or cefazolin, using propensity score analysis with the inverse probability of treatment weighting (IPTW) method. RESULTS: We evaluated 373 patients with MSSA bacteraemia. Among them, 198 patients met the eligibility criteria, including 127 patients in the BL/BLICs group and 71 patients in the cloxacillin/cefazolin group. Patients in the BL/BLICs group had a higher Charlson comorbidity index (median, 2 [IQR, 1-4.5] versus 2 [IQR, 0-4]); an increased proportion of high-risk sources (i.e. endocarditis, respiratory sources and bacteraemia of unknown origin [34.6% versus 18.3%]); and an earlier start of antibiotic treatment (median, 0â days [IQR, 0-0] versus 1â day [IQR, 1-2]). Thirty day mortality did not significantly differ between the BL/BLICs and the cloxacillin/cefazolin groups (27 patients [21.3%] versus 13 patients [18.3%]; IPTW-adjusted ORâ=â0.53 [95% CI, 0.18-1.51]). For secondary outcomes, 7â day mortality and 90â day relapse were not statistically different between study groups (8.7% versus 5.6% [Pâ=â0.62] and 6.2% versus 3.8% [Pâ=â0.81], respectively). CONCLUSIONS: BL/BLICs might be an effective empirical treatment for MSSA bacteraemia when de-escalated to cloxacillin or cefazolin within 96â h from the index blood culture.
Assuntos
Bacteriemia , Infecções Estafilocócicas , Adulto , Antibacterianos/farmacologia , Bacteriemia/tratamento farmacológico , Cefazolina/uso terapêutico , Cloxacilina/farmacologia , Cloxacilina/uso terapêutico , Estudos de Coortes , Humanos , Lactamas/farmacologia , Meticilina/farmacologia , Estudos Retrospectivos , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus aureus , Inibidores de beta-Lactamases/farmacologia , Inibidores de beta-Lactamases/uso terapêutico , beta-Lactamas/farmacologia , beta-Lactamas/uso terapêuticoRESUMO
BACKGROUND: We aimed to determine whether daptomycin plus fosfomycin provides higher treatment success than daptomycin alone for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and endocarditis. METHODS: A randomized (1:1) phase 3 superiority, open-label, and parallel group clinical trial of adult inpatients with MRSA bacteremia was conducted at 18 Spanish hospitals. Patients were randomly assigned to receive either 10 mg/kg of daptomycin intravenously daily plus 2 g of fosfomycin intravenously every 6 hours, or 10 mg/kg of daptomycin intravenously daily. Primary endpoint was treatment success 6 weeks after the end of therapy. RESULTS: Of 167 patients randomized, 155 completed the trial and were assessed for the primary endpoint. Treatment success at 6 weeks after the end of therapy was achieved in 40 of 74 patients who received daptomycin plus fosfomycin and in 34 of 81 patients who were given daptomycin alone (54.1% vs 42.0%; relative risk, 1.29 [95% confidence interval, .93-1.8]; Pâ =â .135). At 6 weeks, daptomycin plus fosfomycin was associated with lower microbiologic failure (0 vs 9 patients; Pâ =â .003) and lower complicated bacteremia (16.2% vs 32.1%; Pâ =â .022). Adverse events leading to treatment discontinuation occurred in 13 of 74 patients (17.6%) receiving daptomycin plus fosfomycin, and in 4 of 81 patients (4.9%) receiving daptomycin alone (Pâ =â .018). CONCLUSIONS: Daptomycin plus fosfomycin provided 12% higher rate of treatment success than daptomycin alone, but this difference did not reach statistical significance. This antibiotic combination prevented microbiological failure and complicated bacteremia, but it was more often associated with adverse events. CLINICAL TRIALS REGISTRATION: NCT01898338.
Assuntos
Bacteriemia , Daptomicina , Endocardite , Fosfomicina , Staphylococcus aureus Resistente à Meticilina , Infecções Estafilocócicas , Adulto , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Daptomicina/uso terapêutico , Endocardite/tratamento farmacológico , Fosfomicina/uso terapêutico , Humanos , Infecções Estafilocócicas/tratamento farmacológico , Resultado do TratamentoRESUMO
Ten cases of ertapenem neurotoxicity, mainly confusional states, are described, some of them with fatal outcomes. The majority of patients (90%) had a creatinine clearance (CrCl) < 50 mL/min/1.73m2 at some point during treatment and hypoalbuminaemia was always present when ertapenem treatment was started. The pharmacokinetic and pharmacodynamic properties of this carbapenem could favour a different profile, and approved doses can be excessive in some patients with moderate renal failure (CrCl 31-59 mL/min/1.73 m2 ). It may be necessary to re-evaluate renal function during treatment and adjust doses or reconsider the adequacy of treatment based on clinical judgement, especially if relevant changes in the CrCl occur (i.e. a reduction to ≤30 mL/min/1.73 m2 ) or unexplained behavioural disorders are detected. The onset of the symptoms of ertapenem neurotoxicity can be insidious and go unnoticed, and so a knowledge and early suspicion of confusional states are important to improve the patient prognosis.
Assuntos
Hipoalbuminemia , Síndromes Neurotóxicas , Insuficiência Renal , Antibacterianos/efeitos adversos , Confusão/induzido quimicamente , Ertapenem , Humanos , Síndromes Neurotóxicas/etiologiaRESUMO
PURPOSE: To evaluate preoperative asymptomatic bacteriuria (ASB) treatment to reduce early-periprosthetic joint infections (early-PJIs) after hip hemiarthroplasty (HHA) for fracture. METHODS: Open-label, multicenter RCT comparing fosfomycin-trometamol versus no intervention with a parallel follow-up cohort without ASB. PRIMARY OUTCOME: early-PJI after HHA. RESULTS: Five hundred ninety-four patients enrolled (mean age 84.3); 152(25%) with ASB (77 treated with fosfomycin-trometamol/75 controls) and 442(75%) without. Despite the study closed without the intended sample size, ASB was not predictive of early-PJI (OR: 1.06 [95%CI: 0.33-3.38]), and its treatment did not modify early-PJI incidence (OR: 1.03 [95%CI: 0.15-7.10]). CONCLUSIONS: Neither preoperative ASB nor its treatment appears to be risk factors of early-PJI after HHA. ClinicalTrials.gov Identifier: Eudra CT 2016-001108-47.
Assuntos
Artroplastia de Quadril/efeitos adversos , Bacteriúria/microbiologia , Artropatias/microbiologia , Infecções Relacionadas à Prótese/microbiologia , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Infecções Assintomáticas/terapia , Bacteriúria/tratamento farmacológico , Bacteriúria/etiologia , Feminino , Fosfomicina/uso terapêutico , Humanos , Artropatias/tratamento farmacológico , Artropatias/etiologia , Masculino , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/etiologia , Trometamina/uso terapêuticoRESUMO
BACKGROUND: Second-stage positive cultures in 2-stage revision arthroplasty are a matter of concern, as their influence in outcomes is not clearly defined. We sought to study reimplantation microbiology when using vancomycin-gentamicin prefabricated cement spacers in hip and knee periprosthetic joint infection. The associations of second-stage positive cultures with treatment failures and patient-associated factors were analyzed. METHODS: We conducted a retrospective cohort study, examining patients managed with 2-stage revision arthroplasty due to knee or hip chronic periprosthetic joint infection between 2010 and 2017. Prefabricated vancomycin-gentamicin cement spacers were used during the spacer stage. Intraoperative microbiological culture results after the first and second stages were evaluated. The primary end point was infection eradication or relapse. RESULTS: A total of 108 cases were included (61 hips and 47 knees). And 22.2% of patients had ≥1 second-stage positive culture, while 9.3% had ≥2 positive samples. Overall success, at an average follow-up of 46.4 months, was 77.8%. Treatment failure was higher among cases with positive cultures (15.5% vs 45.8%, P < .01) regardless of the number of positive samples. Diabetes was identified as a risk factor for second-stage positive cultures (P = .03); use of cement loaded with extra antibiotics for spacer fixation showed a protective effect (P < .01). CONCLUSION: Second-stage positive cultures were related to a higher failure rate when using vancomycin-gentamicin cement spacers. Diabetes increased the likelihood of second-stage positive cultures. The use of extra-antibiotic-loaded cement for spacer fixation during the first stage showed a protective effect.
Assuntos
Artroplastia de Quadril , Infecções Relacionadas à Prótese , Antibacterianos/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Cimentos Ósseos , Gentamicinas , Humanos , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/prevenção & controle , Reoperação , Reimplante , Estudos Retrospectivos , VancomicinaRESUMO
BACKGROUND: Oral switch to linezolid is a promising alternative to standard parenteral therapy (SPT) in Staphylococcus aureus bacteremia (SAB). METHODS: We conducted a prospective cohort study of all adult cases of SAB between 2013 and 2017 in a Spanish university hospital. We compared the efï¬cacy, safety, and length of hospital stay of patients receiving SPT and those where SPT was switched to oral linezolid between days 3 and 9 of treatment until completion. We excluded complicated SAB and osteoarticular infections. A k-nearest neighbor algorithm was used for propensity score matching with a 2:1 ratio. RESULTS: After propensity score matching, we included 45 patients from the linezolid group and 90 patients from the SPT group. Leading SAB sources were catheter related (49.6%), unknown origin (20.0%), and skin and soft tissue (17.0%). We observed no difference in 90-day relapse between the linezolid group and the SPT group (2.2% vs 4.4% respectively; P = .87). No statistically significant difference was observed in 30-day all-cause mortality between the linezolid group and the SPT group (2.2% vs 13.3%; P = .08). The median length of hospital stay after onset was 8 days in the linezolid group and 19 days in the SPT group (P < .01). No drug-related events leading to discontinuation were noted in the linezolid group. CONCLUSIONS: Treatment of SAB in selected low-risk patients with an oral switch to linezolid between days 3 and 9 of treatment until completion yielded similar clinical outcomes as SPT, allowing earlier discharge from the hospital.
Assuntos
Antibacterianos/administração & dosagem , Bacteriemia/tratamento farmacológico , Substituição de Medicamentos , Linezolida/administração & dosagem , Infecções Estafilocócicas/tratamento farmacológico , Administração Oral , Idoso , Bacteriemia/mortalidade , Feminino , Hospitais Universitários/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Prospectivos , Fatores de Risco , Espanha , Infecções Estafilocócicas/mortalidade , Staphylococcus aureusRESUMO
The study aims to determine whether 8 weeks of antibiotics is non-inferior to 12 weeks in patients with acute deep spinal implant infection (SII). In the retrospective study of all SII cases (2009-2016), patients aged ≥ 15 years with microbiologically confirmed SII treated with debridement and implant retention were included. Whenever possible, tailored antibiotic treatment was used: rifampin/linezolid in gram-positive and quinolones in gram-negative infection. Patients were divided into short treatment course (8 weeks, ST group) and extended treatment (12 weeks, ET group). Primary outcome measure was percentage of cures at 1-year follow-up. One-hundred-twenty-four patients considered, 48 excluded based on the above criteria, leaving 76 patients, 28 ST and 48 ET. There were no differences in patient age, comorbidities, underlying pathologies, infection location, or surgery characteristics between groups. Surgery-to-debridement time was similar (18.5-day ST vs. 19-day ET; P = 0.96). Sixteen SII cases (21.1%) occurred with bloodstream infection. Pathogens found were Enterobacteriaceae (35, 46.1%), Staphylococcus aureus (29, 38.2%), coagulase-negative staphylococci (12, 15.8%), Pseudomonas aeruginosa (12, 15.8%), and Enterococcus faecalis (7, 9.2%). Twenty seven (35.5%) had polymicrobial infection. E. faecalis was more frequent in the ST group (7, 25% vs. 0; P < 0.001), and P. aeruginosa in ET (1, 3.6% vs. 11, 22.9%; P = 0.05). Five patients died of causes unrelated to SII. At 1-year follow-up, cure rates (21/26 ST, 80.8% vs. 39/45 ET, 86.7%; P = 0.52) and recurrences (2/26, 7.7% vs. 2/45, 4.4%; P = 0.62) were similar. Eight-week antimicrobial courses were not inferior to 12 weeks in patients with acute deep SII treated with prompt debridement, proper wound healing, and optimized antibiotics.
Assuntos
Antibacterianos/uso terapêutico , Doenças Ósseas Infecciosas/tratamento farmacológico , Doenças Ósseas Infecciosas/cirurgia , Desbridamento , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/cirurgia , Substituição Total de Disco/efeitos adversos , Doença Aguda , Adulto , Idoso , Antibacterianos/farmacologia , Bactérias/efeitos dos fármacos , Bactérias/isolamento & purificação , Doenças Ósseas Infecciosas/diagnóstico , Doenças Ósseas Infecciosas/microbiologia , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Retenção da Prótese , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/microbiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: To describe the demographic, clinical, and microbiological profile of native vertebral osteomyelitis (NVO) in aged patients as compared to that of younger patients, to identify differences that could motivate changes in clinical management. METHODS: Retrospective, observational cohort study (1990-2015) including all adult patients with microbiologically confirmed NVO divided into 2 groups: aged (≥ 65 years) vs younger (18-64 years). RESULTS: 247 patients included, 138 aged and 109 younger. Relative to younger patients, the aged had higher rates of healthcare-related infection (40.6 vs 25.7%, p = 0.014), previous known heart valve disease (29.7 vs 9.2%, p < 0.001), and concomitant infective endocarditis (38.4 vs 20.2%, p = 0.002). The groups showed similar rates of symptomatic spinal cord compression (14.5 vs 11.9%, p = 0.556) and paraspinal abscesses (62.3 vs 68.8%, p = 0.288) at presentation. There was a trend to lower spine surgery rates in the aged (11.6 vs 17.4%, p = 0.192). On univariate analysis, Staphylococcus aureus infection was associated with higher in-hospital mortality in aged (29%, OR 4.3, 95% CI 1.61-11.45). In-hospital mortality was higher among the aged (14.5 vs 6.4%, p = 0.044) as well as relapse rate due to treatment failure (3.4 vs 1%, p = 0.377). CONCLUSIONS: The findings underscore the importance of preventing healthcare-related infection and maintaining high clinical suspicion of infective endocarditis in aged NVO patients to implement proper management. S. aureus infection had a poorer prognosis in this population. As compared to younger patients, spinal surgery rates were slightly lower and overall prognosis poorer in the aged, despite similar rates of symptomatic spinal cord compression and abscesses at presentation.
Assuntos
Infecção Hospitalar/epidemiologia , Endocardite Bacteriana/epidemiologia , Doenças das Valvas Cardíacas/epidemiologia , Osteomielite/patologia , Doenças da Coluna Vertebral/patologia , Infecções Estafilocócicas/epidemiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Comorbidade , Infecção Hospitalar/etiologia , Endocardite Bacteriana/microbiologia , Feminino , Doenças das Valvas Cardíacas/microbiologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Osteomielite/microbiologia , Osteomielite/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Estudos Retrospectivos , Espanha/epidemiologia , Doenças da Coluna Vertebral/microbiologia , Doenças da Coluna Vertebral/cirurgia , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus/fisiologia , Adulto JovemRESUMO
PURPOSE: The aim of this study was to evaluate the effectiveness of ceftolozane/tazobactam (C/T) for treating extensively drug-resistant Pseudomonas aeruginosa (XDR-PA) infections, and to analyze whether high C/T dosing (2 g ceftolozane and 1 g tazobactam every 8 h) and infection source control have an impact on outcome. METHODS: Retrospective study of all consecutive patients treated with C/T for XDR-PA infection at a tertiary referral hospital (November 2015-July 2017). Main clinical and microbiological variables were analyzed. RESULTS: Thirty-eight patients were included. Median age was 59.5 years and Charlson Comorbidity Index was 3.5. Fourteen (36.8%) patients had respiratory tract infection, six (15.8%) soft tissue, and six (15.8%) urinary tract infection. Twenty-three (60.5%) received high-dose C/T and in 24 (63.2%) C/T was combined with other antibiotics. At completion of treatment, 33 (86.8%) patients showed clinical response. At 90 days of follow-up, 26 (68.4%) achieved clinical cure, and 12 (31.6%) had clinical failure because of persistent infection in one patient, death attributable to the XDR-PA infection in four, and clinical recurrence in seven. All-cause mortality was 5 (13.2%). Lower C/T MIC and adequate infection source control were the only variables significantly associated with clinical cure. CONCLUSIONS: C/T should be considered for treating XDR-PA infections, with infection source control being an important factor to avoid failure and resistance.
Assuntos
Cefalosporinas/uso terapêutico , Farmacorresistência Bacteriana/efeitos dos fármacos , Ácido Penicilânico/análogos & derivados , Infecções por Pseudomonas/tratamento farmacológico , Infecções por Pseudomonas/microbiologia , Pseudomonas aeruginosa/efeitos dos fármacos , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Cefalosporinas/farmacologia , Feminino , Seguimentos , Humanos , Controle de Infecções , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Ácido Penicilânico/farmacologia , Ácido Penicilânico/uso terapêutico , Infecções por Pseudomonas/diagnóstico , Pseudomonas aeruginosa/classificação , Pseudomonas aeruginosa/genética , Estudos Retrospectivos , Tazobactam , Falha de Tratamento , Resultado do Tratamento , Adulto JovemRESUMO
Fusobacterium nucleatum is an obligately anaerobic gram-negative rod, a component of the microbiome of the oropharynx and the gastrointestinal and urogenital tracts, causing an array of human infections which often include periodontal pathologies. As far as we know, there are no previous publications about acute periprosthetic joint infection due to Fusobacterium sp.; we report the first case in the medical literature of an aggressive, acute knee prosthetic infection due to F. nucleatum in a non-immunocompromised patient, unsuccessfully treated with a DAIR approach (Debridement + Antibiotics + Implant Retention).
Assuntos
Infecções por Fusobacterium/microbiologia , Fusobacterium nucleatum/fisiologia , Infecções Relacionadas à Prótese/microbiologia , Idoso , Antibacterianos/administração & dosagem , Desbridamento , Feminino , Infecções por Fusobacterium/tratamento farmacológico , Infecções por Fusobacterium/cirurgia , Fusobacterium nucleatum/efeitos dos fármacos , Humanos , Artropatias/tratamento farmacológico , Artropatias/microbiologia , Artropatias/cirurgia , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/cirurgia , Falha de TratamentoRESUMO
OBJECTIVE: Describe secular trends in the epidemiology and outcome of Clostridium difficile infection (CDI) at a tertiary hospital. METHODS: All consecutive primary CDI episodes in adults (January 2006-December 2015) were included. CDI was diagnosed on the presence of diarrhoea and a positive stool test for C. difficile toxin A and/or B. To define trends, a time-series analysis was performed using yearly data on demographics, clinical characteristics, management, antimicrobial treatment, and outcome of CDI. Patients were followed-up for three months after the diagnosis. RESULTS: There were 724 CDI episodes. Over the period from 2006 to 2015, the incidence rose from 0.18 episodes/1000 admissions to 0.26 episodes (relative rate [RR] 1.43; 95%CI, 1.02-2.00; Pâ¯=â¯0.035). Median Charlson comorbidity index increased from 2 (IQR 1-3) to 4 (IQR 2-4) (RR 1.65; 95%CI, 1.12-2.41; Pâ¯=â¯0.005). Overall, 80.4% of patients received proton pump inhibitors (PPIs) prior to CDI, and the percentage of PPI discontinuations rose from 2.3% to 20.4% (RR 8.80; 95%CI 1.20-64.36; Pâ¯=â¯0.006). Management of non-Clostridium antibiotics also changed: antibiotic withdrawals or switches increased from 4.2% to 29.2% (RR 7.00; 95%CI 1.68-29.15, Pâ¯=â¯0.001). Regarding CDI treatment, the percentage of patients treated with metronidazole decreased (88.9% vs 52.6%) (RR 0.59 (0.48-0.73), Pâ¯<â¯0.001), whereas the percentage receiving vancomycin increased (1.9% vs 32.6%) (RR 17.62 (2.47-125.49), Pâ¯<â¯0.001). The percentages of cures, deaths, and first recurrences did not significantly change over the 10-year period. CONCLUSIONS: Changes in CDI management were associated with a stable prognosis (percentage of cures and first recurrences), even though affected patients had a greater number of comorbidities over time.
Assuntos
Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Técnicas Bacteriológicas , Infecções por Clostridium/tratamento farmacológico , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Espanha/epidemiologia , Centros de Atenção Terciária , Resultado do Tratamento , Adulto JovemRESUMO
The aim of the current study was to compare community-acquired acute pyelonephritis (CA-APN) with health care-associated acute pyelonephritis (HCA-APN), describe the outcomes, and identify variables that could predict antimicrobial susceptibility. We conducted an observational study that included all consecutive episodes of acute pyelonephritis (APN) in adults during 2014 at a Spanish university hospital. From each episode, demographic data, comorbidities, clinical presentation, microbiological data, antimicrobial therapy, and outcome were recorded. A multivariable logistic regression model was performed to define the variables associated with antimicrobial resistance. A total of 607 patients, 503 (82.9%) with CA-APN and 104 (17.1%) with HCA-APN, were included in the study. Patients with HCA-APN were older than patients with CA-APN (70.4 versus 50.6 years; P < 0.001) and had higher rates of previous urinary tract infections (UTIs) (56.5% versus 24.5%; P < 0.001) and previous antibiotic use (56.8% versus 22.8%; P < 0.001). Escherichia coli was more frequently isolated from patients with CA-APN than from patients with HCA-APN (79.9% versus 50.5%; P < 0.001). The rates of resistance of Escherichia coli strains from CA-APN patients versus HCA-APN patients were as follows: amoxicillin-clavulanic acid, 22.4% versus 53.2% (P = 0.001); cefuroxime, 7.7% versus 43.5% (P = 0.001); cefotaxime, 4.3% versus 32.6% (P < 0.001); ciprofloxacin, 22.8% versus 74.5% (P < 0.001); and co-trimoxazole, 34.5% versus 58.7% (P = 0.003). The site of acquisition, recurrent UTIs, and previous antibiotic use were independent risk factors for antimicrobial resistance. Relapse rates were significantly higher when definitive antimicrobial treatment was not adequate (37.1% versus 9.3% when definitive antimicrobial treatment was adequate; P < 0.001). Our study reflects the rise of resistance to commonly used antibiotics in acute pyelonephritis. In order to choose the adequate empirical antibiotic therapy, risk factors for resistance should be considered.
Assuntos
Antibacterianos/uso terapêutico , Infecção Hospitalar/tratamento farmacológico , Farmacorresistência Bacteriana , Infecções por Escherichia coli/tratamento farmacológico , Escherichia coli/efeitos dos fármacos , Pielonefrite/tratamento farmacológico , Infecções Urinárias/tratamento farmacológico , Doença Aguda , Adulto , Idoso , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Cefotaxima/uso terapêutico , Cefuroxima/uso terapêutico , Ciprofloxacina/uso terapêutico , Estudos de Coortes , Infecções Comunitárias Adquiridas , Infecção Hospitalar/microbiologia , Infecção Hospitalar/patologia , Pesquisa Empírica , Escherichia coli/crescimento & desenvolvimento , Infecções por Escherichia coli/microbiologia , Infecções por Escherichia coli/patologia , Feminino , Hospitais Universitários , Humanos , Modelos Logísticos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Pielonefrite/microbiologia , Pielonefrite/patologia , Fatores de Risco , Espanha , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Infecções Urinárias/microbiologia , Infecções Urinárias/patologiaRESUMO
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.
Assuntos
Infecções Urinárias/diagnóstico , Infecções Urinárias/tratamento farmacológico , Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Carga Bacteriana , Bacteriúria/microbiologia , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/tratamento farmacológico , Infecções Relacionadas a Cateter/microbiologia , Infecções Relacionadas a Cateter/prevenção & controle , Resistência Microbiana a Medicamentos , Feminino , Humanos , Infectologia/organização & administração , Infectologia/normas , Masculino , Microbiologia/organização & administração , Microbiologia/normas , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/tratamento farmacológico , Complicações Infecciosas na Gravidez/microbiologia , Sociedades Médicas , Cateterismo Urinário/efeitos adversos , Infecções Urinárias/microbiologia , Infecções Urinárias/prevenção & controleRESUMO
We report 2 cases of recurrent Campylobacter coli enteritis caused by macrolide- and fluoroquinolone-resistant strains in 2 patients with hypogammaglobulinemia, successfully treated with a prolonged course of fosfomycin-tromethamine with no side effects. Fosfomycin-tromethamine may be a feasible alternative therapy for recurrent enteritis caused by Campylobacter species resistant to first-line drugs.
Assuntos
Antibacterianos/uso terapêutico , Campylobacter/efeitos dos fármacos , Campylobacter/patogenicidade , Enterite/tratamento farmacológico , Fosfomicina/uso terapêutico , Trometamina/uso terapêutico , Agamaglobulinemia/tratamento farmacológico , Idoso de 80 Anos ou mais , Feminino , Humanos , Testes de Sensibilidade Microbiana , Pessoa de Meia-IdadeRESUMO
This is a retrospective study of 15 difficult-to-treat (i.e., exhibiting previous failure, patient side effects, or resistance to ciprofloxacin and co-trimoxazole) chronic bacterial prostatitis infections (5 patients with multidrug-resistant Enterobacteriaceae [MDRE]) receiving fosfomycin-tromethamine at a dose of 3 g per 48 to 72 h for 6 weeks. After a median follow-up of 20 months, 7 patients (47%) had a clinical response, and 8 patients (53%) had persistent microbiological eradication; 4/5 patients with MDRE isolates achieved eradication. There were no side effects. Fosfomycin-tromethamine is a possible alternative therapy for chronic bacterial prostatitis.
Assuntos
Antibacterianos/uso terapêutico , Ciprofloxacina/uso terapêutico , Farmacorresistência Bacteriana Múltipla , Fosfomicina/uso terapêutico , Prostatite/tratamento farmacológico , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Prostatite/microbiologia , Estudos Retrospectivos , Trometamina , Adulto JovemRESUMO
Two-stage revision using aminoglycoside-cement spacers (A-CSs) is widely used to manage chronic periprosthetic joint infection (PJI). However, aminoglycoside-resistance in gram-positive cocci (GPC) seems to be increasing. Moreover, the contribution of these A-CSs to select resistant mutants is a matter of concern. We study the antibiotic susceptibility profile of GPC after 113 chronic hip and knee PJIs. Aminoglycoside susceptibility-profiles were compared between cases where A-CSs had previously been used (n: 52), and cases of primary infection (n: 61). 32% of isolates were resistant to gentamicin and 40.6% to tobramycin. Gentamicin resistance after previous A-CS use was significantly higher (49.2% [30/61] vs. 19.3% [16/83]; P: 0.0001) as well as with tobramycin (52.7% [29/55] vs. 30.9% [21/66]; P: 0.014). A high rate of gentamicin-tobramycin resistance exists among the most common bacteria involved in chronic-PJI. The risk of selection for aminoglycoside-resistant mutants in cases of infection relapse is a concern following A-CS use.
Assuntos
Antibacterianos/administração & dosagem , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/cirurgia , Idoso , Idoso de 80 Anos ou mais , Cimentos Ósseos/uso terapêutico , Doença Crônica , Farmacorresistência Bacteriana , Feminino , Gentamicinas/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Prevenção Secundária , Tobramicina/administração & dosagemRESUMO
PURPOSE: Preoperative identification of the infecting micro-organism is of paramount importance in the treatment protocol for chronic periprosthetic joint infections, as it enables selection of the most appropriate antibiotic treatment. Preoperative joint aspiration, the most commonly used sampling technique, has proven to have a broad range of sensitivity values and the frequency of dry aspirations has not been well assessed. In such dry-tap cases a biopsy sample could be an option. The purpose of this study was to assess the diagnostic accuracy of percutaneous interface biopsy (PIB) in isolating the infecting organism in cases of chronic Periprosthetic Joint Infection (PJI) and dry-tap event. The basic technique is to harvest and culture a sample from the periprosthetic interface membrane by a percutaneous technique in the preoperative period. METHODS: A retrospective study was done involving 24 consecutive patients suspected of PJI and where no fluid was obtained from the joint. Culture results from a percutaneous interface biopsy (PIB) were compared with intraoperative tissue cultures at the time of revision surgery. In all cases, a two-stage replacement was done. RESULTS: The sensitivity was 88.2%; specificity was 100%. Positive predictive value was 100%, while negative predictive value was 77.9%. Accuracy was 91.6%. No technique-related complication was observed. CONCLUSION: We conclude that PIB is a useful test for preoperative isolation of the infecting organism and could play a role in cases with dry-tap joint aspirations.
Assuntos
Artrite Infecciosa/diagnóstico , Bactérias/isolamento & purificação , Articulação do Quadril/patologia , Articulação do Joelho/patologia , Infecções Relacionadas à Prótese/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Artrite Infecciosa/microbiologia , Biópsia/métodos , Feminino , Articulação do Quadril/microbiologia , Humanos , Articulação do Joelho/microbiologia , Masculino , Testes de Sensibilidade Microbiana , Técnicas Microbiológicas , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/microbiologia , Reoperação , Estudos RetrospectivosRESUMO
BACKGROUND AND OBJECTIVE: To determine the etiology and susceptibility of uropathogens identified in women with uncomplicated lower urinary tract infections (UTI). PATIENTS AND METHODS: In a multicenter study (ARESC) in 9 Spanish hospitals, 803 female patients with uncomplicated cystitis were consecutively enrolled and evaluated to identify the uropathogens and their susceptibility to 9 antimicrobials. RESULTS: Of 803 patients with uncomplicated cystitis, 784 patients were included. A positive urine culture was found in 87.7% of the samples. Of the 650 pathogens isolated, Escherichia coli (E. coli) was the most frequent (79.2%) followed by Staphylococcus saprophyticus (4.4%), Proteus mirabilis (4.3%), Enterococcus faecalis (3.2%) and Klebsiella pneumoniae (2.3%). E. coli showed a high rate of susceptibility to phosphomycin (97.2%), nitrofurantoin (94.1%) and somewhat lower to ciprofloxacin (88.1%). Fluorquinolone resistance rates were higher among postmenopausal women (17 versus 10%). E. coli was highly resistant to ampicillin (65%) and cotrimoxazole (34%) and 25% of the strains were resistant to amoxicillin/clavulanalic acid and cefuroxime. CONCLUSIONS: In Spain, E. coli shows high resistance rates to widely used antimicrobial antibiotics. Phosphomycin and nitrofurantoin have a high in vitro activity. Taking into account practical aspects such as convenience (only one dose), and the influence of the amount of fluorquinolone use on enterobacteriaceae and other microorganisms resistance levels, phosphomycin trometamol represents the option of first choice for the empirical treatment of uncomplicated cystitis in women.
Assuntos
Cistite/microbiologia , Enterococcus faecalis/efeitos dos fármacos , Klebsiella pneumoniae/efeitos dos fármacos , Proteus mirabilis/efeitos dos fármacos , Staphylococcus saprophyticus/efeitos dos fármacos , Escherichia coli Uropatogênica/efeitos dos fármacos , Adulto , Idoso , Antibacterianos/uso terapêutico , Cistite/tratamento farmacológico , Feminino , Humanos , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Estudos Prospectivos , Infecções Urinárias/microbiologia , Adulto JovemRESUMO
Candida periprosthetic joint infection (CPJI) is a rare and very difficult to treat infection, and high-quality evidence regarding the best management is scarce. Candida spp. adhere to medical devices and grow forming biofilms, which contribute to the persistence and relapse of this infection. Typically, CPJI presents as a chronic infection in a patient with multiple previous surgeries and long courses of antibiotic therapy. In a retrospective series of cases, the surgical approach with higher rates of success consists of a two-stage exchange surgery, but the best antifungal treatment and duration of antifungal treatment are still unclear, and the efficacy of using an antifungal agent-loaded cement spacer is still controversial. Until more evidence is available, focusing on prevention and identifying patients at risk of CPJI seems more than reasonable.
RESUMO
We review antibiotic and other prophylactic measures to prevent periprosthetic joint infection (PJI) after hip hemiarthroplasty (HHA) surgery in proximal femoral fractures (PFFs). In the absence of specific guidelines, those applied to these individuals are general prophylaxis guidelines. Cefazolin is the most widely used agent and is replaced by clindamycin or a glycopeptide in beta-lactam allergies. A personalized antibiotic scheme may be considered when colonization by a multidrug-resistant microorganism (MDRO) is suspected. Particularly in methicillin-resistant Staphylococcus aureus (MRSA) colonization or a high prevalence of MRSA-caused PJIs a glycopeptide with cefazolin is recommended. Strategies such as cutaneous decolonization of MDROs, mainly MRSA, or preoperative asymptomatic bacteriuria treatment have also been addressed with debatable results. Some areas of research are early detection protocols in MDRO colonizations by polymerase-chain-reaction (PCR), the use of alternative antimicrobial prophylaxis, and antibiotic-impregnated bone cement in HHA. Given that published evidence addressing PJI prophylactic strategies in PFFs requiring HHA is scarce, PJIs can be reduced by combining different prevention strategies after identifying individuals who will benefit from personalized prophylaxis.