Identification of hospitalized patients with community-acquired infection in whom treatment guidelines do not apply: a validated model.

OBJECTIVES: To develop and validate a clinical model to identify patients admitted to hospital with community-acquired infection (CAI) caused by pathogens resistant to antimicrobials recommended in current CAI treatment guidelines. METHODS: International prospective cohort study of consecutive patients admitted with bacterial infection. Logistic regression was used to associate risk factors with infection by a resistant organism. The final model was validated in an independent cohort. RESULTS: There were 527 patients in the derivation and 89 in the validation cohort. Independent risk factors identified were: atherosclerosis with functional impairment (Karnofsky index <70) [adjusted OR (aOR) (95% CI) = 2.19 (1.41-3.40)]; previous invasive procedures [adjusted OR (95% CI) = 1.98 (1.28-3.05)]; previous colonization with an MDR organism (MDRO) [aOR (95% CI) = 2.67 (1.48-4.81)]; and previous antimicrobial therapy [aOR (95% CI) = 2.81 (1.81-4.38)]. The area under the receiver operating characteristics (AU-ROC) curve (95% CI) for the final model was 0.75 (0.70-0.79). For a predicted probability ≥22% the sensitivity of the model was 82%, with a negative predictive value of 85%. In the validation cohort the sensitivity of the model was 96%. Using this model, unnecessary broad-spectrum therapy would be recommended in 30% of cases whereas undertreatment would occur in only 6% of cases. CONCLUSIONS: For patients hospitalized with CAI and none of the following risk factors: atherosclerosis with functional impairment; previous invasive procedures; antimicrobial therapy; or MDRO colonization, CAI guidelines can safely be applied. Whereas, for those with some of these risk factors, particularly if more than one, alternative antimicrobial regimens should be considered.

[Gemella endocarditis: an aggressive entity]. / Endocardite por Gemella: uma entidade agressiva.

The authors present a rare case of subacute endocarditis caused by Gemella morbillorum. A 72-year-old man, with a history of hypertension, aortic valve disease and upper and lower endoscopy six months previously, was admitted due to fever and abdominal pain. He also complained of long-standing dyspnea on exertion and petechiae on his lower limbs. Imaging scans showed a consolidation in the lower left lung field, a splenic infarct and a left subphrenic abscess. Transthoracic echocardiogram findings were highly suggestive of endocarditis affecting three valves, with destruction of the mitral valve anterior leaflet. G. morbillorum was identified in three blood cultures and was considered the etiologic pathogen. Due to the patient's worsening condition, he underwent cardiac surgery, aiming to control the infection and to resolve the associated mechanical complications. This case highlights the need for a complete and thorough history to arrive at likely diagnostic hypotheses that, together with complementary exams, will lead to correct diagnosis and the prompt institution of appropriate therapy.