Listeria monocytogenes meningoencephalitis in adults: analysis of factors related to unfavourable outcome.

PURPOSE: To analyse the short-term outcome in patients with Listeria monocytogenes meningoencephalitis (LMME) to improve management and outcome. METHODS: Observational study with adult patients with LMME between 1977 and 2009 at a tertiary hospital in Barcelona, Spain. Parameters that predicted outcome were assessed with univariate and logistic regression analysis. RESULTS: Of 59 cases of LMME, 28 occurred in the last decade. Since 1987, a new protocol has been used and 29/45 patients (64%) treated since then received adjuvant dexamethasone. In patients who received this treatment there was a trend towards fewer neurological sequelae (5 vs 33%; p = 0.052). Antiseizure prophylaxis with phenytoin was administered in 13/45 (28%) patients. Seizures occurred in 7/45 (16%) patients, all in the group who did not receive phenytoin. Hydrocephalus presented in 8/59 (14%). It was never present at admission and five patients needed neurosurgical procedures. Sequelae after 3 months were present in 8/45 (18%), mostly cranial nerve palsy. Rhombencephalitis (RE) was related to the presence of neurologic sequelae (OR: 20.4, 95% CI: 1.76-236). Overall mortality was 14/59 (24%), 9/59 (15%) due to neurological causes related to hydrocephalus or seizures. Mortality was defined as early in 36% and late in 64%. In the multivariate analysis, independent risk factors for mortality were presence of hydrocephalus (OR: 17.8, 95% CI: 2.753-114) and inappropriate empirical antibiotic therapy (OR: 6.5, 95% CI: 1.201-35). CONCLUSIONS: Outcome of LMME may be improved by appropriate empirical antibiotic therapy, suspicion and careful management of hydrocephalus. Use of adjuvant dexamethasone or phenytoin in a subgroup of these patients might have a benefit.

Fosfomycin-daptomycin and other fosfomycin combinations as alternative therapies in experimental foreign-body infection by methicillin-resistant Staphylococcus aureus.

The efficacy of daptomycin, imipenem, or rifampin with fosfomycin was evaluated and compared with that of daptomycin-rifampin in a tissue cage model infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Strain HUSA 304 was used. The study yielded the following results for MICs (in µg/ml): fosfomycin, 4; daptomycin, 1; imipenem, 0.25; and rifampin, 0.03. The study yielded the following results for minimum bactericidal concentration (MBC) (in µg/ml): fosfomycin, 8; daptomycin, 4; imipenem, 32; and rifampin, 0.5. Daptomycin-rifampin was confirmed as the most effective therapy against MRSA foreign-body infections. Fosfomycin combinations with high doses of daptomycin and rifampin were efficacious alternative therapies in this setting. Fosfomycin-imipenem was relatively ineffective and did not protect against resistance.

Efficacy of daptomycin-cloxacillin combination in experimental foreign-body infection due to methicillin-resistant Staphylococcus aureus.

Despite the use of daptomycin alone at high doses (greater than 6 mg/kg of body weight/day) against difficult-to-treat infections, clinical failures and resistance appeared. Recently, the combination daptomycin-cloxacillin showed enhanced efficacy in clearing bacteremia caused by methicillin-resistant Staphylococcus aureus (MRSA). The aim of this study was to evaluate the efficacy of daptomycin at usual and high doses (equivalent to 6 and 10 mg/kg/day in humans, respectively) in combination with cloxacillin in a rat tissue cage infection model by MRSA and to compare its efficacy to that of daptomycin-rifampin. We used MRSA strain ATCC BAA-39. In the log- and stationary-phase kill curves, daptomycin-cloxacillin improved the bactericidal activity of daptomycin, especially in log phase. For in vivo studies, therapy was administered intraperitoneally for 7 days with daptomycin at 100 mg/kg/day and 45/mg/kg/day (daptomycin 100 and daptomycin 45), daptomycin 100-cloxacillin at 200 mg/kg/12 h, daptomycin 45-cloxacillin, and daptomycin 100-rifampin at 25 mg/kg/12 h. Daptomycin-rifampin was the best therapy (P < 0.05). Daptomycin 45 was the least effective treatment and did not protect against the emergence of resistant strains. There were no differences between the two dosages of daptomycin plus cloxacillin in any situation, and both protected against resistance. The overall effect of the addition of cloxacillin to daptomycin was a significantly greater cure rate (against adhered bacteria) than that for daptomycin alone. In conclusion, daptomycin-cloxacillin enhanced modestly the in vivo efficacy of daptomycin alone against foreign-body infection by MRSA and was less effective than daptomycin plus rifampin. The benefits of adding cloxacillin to daptomycin should be especially evaluated against infections by rifampin-resistant MRSA and for protection against the emergence of daptomycin nonsusceptibility.

Arthritis related to systemic meningococcal disease: 34 years' experience.

The purpose of this investigation was to assess the clinical characteristics, therapeutic aspects, and outcome of arthritis related to invasive meningococcal disease (IMD). All episodes of bacterial meningitis and IMD are recorded systematically. We selected all episodes of IMD, with or without meningitis, that presented arthritis. From 1977 to 2010, 522 episodes of IMD were treated. Thirty-nine of these (7.5 %, 26 women, mean age 33 years) presented arthritis. Of these 39, 37 (95 %) presented skin lesions and 31 (79 %) had meningitis. Twenty (51 %) had positive blood cultures and six (15 %) had shock. No differences were found in skin lesions, shock, or bacteremia compared to cases without arthritis. In contrast to other septic forms, arthritis related to IMD was cured with short antibiotic therapy and without surgical drainage. There was no mortality. All patients recovered and none presented joint sequelae; however, 13 adult patients (33 %) required long-term treatment with steroids due to persistent symptoms. Arthritis related to IMD most frequently affects the knees and ankles, and may be a cause of fever relapse. Short antibiotic therapy is enough in all cases and surgical drainage is not needed. In some adult patients, especially those over 50 years of age, evolution is torpid and steroid therapy may be required in order to achieve recovery.

Efficacy of usual and high doses of daptomycin in combination with rifampin versus alternative therapies in experimental foreign-body infection by methicillin-resistant Staphylococcus aureus.

The treatment of prosthetic joint infections caused by methicillin-resistant Staphylococcus aureus (MRSA) continues to be a challenge for the clinician. The aim of this study was to evaluate the efficacies of daptomycin at usual and high doses (equivalent to 6 and 10 mg/kg of body weight/day, respectively, in humans) and in combination with rifampin and to compare the activities to those of conventional anti-MRSA therapies. We used MRSA strain HUSA 304, with the following MICs and minimal bactericidal concentrations (MBCs), respectively: daptomycin, 1 µg/ml and 4 µg/ml; vancomycin, 2 µg/ml and 4 µg/ml; linezolid, 2 µg/ml and >32 µg/ml; and rifampin, 0.03 µg/ml and 0.5 µg/ml. In time-kill curves, only daptomycin and its combinations with rifampin achieved a bactericidal effect in log and stationary phases. For in vivo studies, we used a rat foreign-body infection model. Therapy was administered for 7 days with daptomycin at 100 mg/kg/day and 45/mg/kg/day, vancomycin at 50 mg/kg/12 h, rifampin at 25 mg/kg/12 h, and linezolid at 35 mg/kg/12 h, and each antibiotic was also combined with rifampin. Among monotherapies, daptomycin at 100 mg/kg/day and rifampin performed better than vancomycin and linezolid. In combination with rifampin, both dosages of daptomycin were significantly better than all other combinations, but daptomycin at 100 mg/kg/day plus rifampin achieved better cure rates at day 11 (P < 0.05) than daptomycin at 45 mg/kg/day plus rifampin. Resistant strains were found in monotherapies with rifampin and daptomycin at 45 mg/kg/day. In conclusion, daptomycin at high doses was the most effective monotherapy and also improved the efficacy of the combination with rifampin against foreign-body infections by MRSA. Clinical studies should confirm whether this combination may be considered the first-line treatment for foreign-body infections by MRSA in humans.

Pilot study of ampicillin-ceftriaxone combination for treatment of orthopedic infections due to Enterococcus faecalis.

Serious Enterococcus faecalis infections usually require combination therapy to achieve a bactericidal effect. In orthopedic infections, the prognosis of enterococcal etiology is considered poor, and the use of aminoglycosides is questioned. The ampicillin-ceftriaxone combination has recently been accepted as alternative therapy for enterococcal endocarditis. After one of our patients with endocarditis and vertebral osteomyelitis was cured with ampicillin-ceftriaxone, we started a pilot study of orthopedic infections. Patients with infections due to E. faecalis (with two or more surgical samples or blood cultures) diagnosed during 2005 to 2008 were recruited. Polymicrobial infections with ampicillin- and ceftriaxone-resistant microorganisms were excluded. Patients received ampicillin (8 to 16 g/day)-ceftriaxone (2 to 4 g/day) and were followed up prospectively. Of 31 patients with E. faecalis infections, 10 received ampicillin-ceftriaxone. Including the first patient, 11 patients were treated with ampicillin-ceftriaxone: 3 with prosthetic joint infections, 3 with instrumented spine arthrodesis device infections, 2 with osteosynthesis device infections, 1 with foot osteomyelitis, and 2 with vertebral osteomyelitis and endocarditis. Six infections (55%) were polymicrobial. All cases except the vertebral osteomyelitis ones required surgery, with retention of foreign material in six cases. Ampicillin-ceftriaxone was given for 25 days (interquartile range, 15 to 34 days), followed by amoxicillin (amoxicilline) being given to seven patients (64%). One patient with endocarditis died within 2 weeks (hemorrhagic stroke) and was not evaluable. For one patient with prosthesis retention, the infection persisted; 9/10 patients (90%) were cured, but 1 patient was superinfected. Follow-up was for 21 months (interquartile range, 14 to 36 months). Ampicillin-ceftriaxone may be a reasonable synergistic combination to treat orthopedic infections due to E. faecalis. Our experience, though limited, shows good outcomes and tolerability and may provide a basis for further well-designed comparative studies.

Efficacy of high doses of daptomycin versus alternative therapies against experimental foreign-body infection by methicillin-resistant Staphylococcus aureus.

Since the currently approved dose of daptomycin (6 mg/kg of body weight/day) has been associated with clinical failures and resistance development, higher doses for some difficult-to-treat infections are being proposed. We studied the efficacy of daptomycin at high doses (equivalent to 10 mg/kg/day in humans) and compared it to that of reference and alternative treatments in a model of foreign-body infection with methicillin (meticillin)-resistant Staphylococcus aureus. In vitro studies were conducted with bacteria in the log and stationary phases. For the in vivo model, therapy with daptomycin at 100 mg/kg/day, vancomycin at 50 mg/kg/12 h, rifampin (rifampicin) at 25 mg/kg/12 h, or linezolid at 35 mg/kg/12 h was administered for 7 days. Antibiotic efficacy was evaluated using either bacteria from tissue cage fluids or those attached to coverslips. We screened for the emergence of linezolid- and rifampin-resistant strains and analyzed the surviving population from the daptomycin-treated group. Only daptomycin was bactericidal in both the log- and stationary-phase studies. Daptomycin (decrease in the log number of CFU per milliliter of tissue cage fluid, 2.57) and rifampin (decrease, 2.6 log CFU/ml) were better (P < 0.05) than vancomycin (decrease, 1.1 log CFU/ml) and linezolid (decrease, 0.9 log CFU/ml) in the animal model. Rifampin-resistant strains appeared in 60% of cases, whereas no linezolid resistance emerged. No daptomycin-resistant subpopulations were detected at frequencies of 10(-7) or higher. In conclusion, daptomycin at high doses proved to be as effective as rifampin, and the two were the most active therapies for this experimental foreign-body infection. These high doses ensured a profile of safety from the development of resistance.

Long-term follow-up trial of oral rifampin-cotrimoxazole combination versus intravenous cloxacillin in treatment of chronic staphylococcal osteomyelitis.

Oral therapies alternative to fluoroquinolones against staphylococcal chronic osteomyelitis have not been evaluated in comparative studies. Consecutive nonaxial Staphylococcus aureus chronic osteomyelitis cases were included in a comparative trial after debridement. Fifty patients were randomized: group A (n = 22) was treated with cloxacillin for 6 weeks intravenously plus 2 weeks orally (p.o.), and group B (n = 28) was treated with rifampin-cotrimoxazole for 8 weeks p.o. During follow-up (10 years), five relapses occurred: two (10%) in group A and three (11%) in group B. Foreign-body maintenance was associated with relapse (P = 0.016). Oral rifampin-cotrimoxazole treatment showed outcomes comparable to those for intravenous cloxacillin treatment.

Intracellular antimicrobial activity appearing as a relevant factor in antibiotic efficacy against an experimental foreign-body infection caused by Staphylococcus aureus.

OBJECTIVES: The presence of bacterial biofilm, tolerance to antibiotics and dysfunctional activity of phagocytic cells are all related to difficulties in eradicating foreign-body infections. We aimed to quantify the presence of intracellular Staphylococcus aureus and to study the extent to which the intracellular activity of antibiotics might determine their efficacy against an experimental rat tissue-cage model of foreign-body infection. METHODS: Using this model, animals were treated for 7 days with 100 mg/kg/day levofloxacin or 200 mg/kg/12 h cloxacillin, or were left untreated. Antibiotic efficacy was evaluated by means of bacterial counts from tissue-cage fluid (TCF); these counts were derived separately in total, intracellular and extracellular bacteria. The presence of intracellular bacteria was checked by electron microscopy. Population analysis was performed with surviving bacteria recovered at the end of levofloxacin therapy. RESULTS: Among a total number of bacteria (mean log cfu/mL +/- SD) from TCF of 6.86 +/- 0.6, we identified 6.38 +/- 0.8 intracellular bacteria and 5.57 +/- 0.5 extracellular bacteria. Levofloxacin was more efficient than cloxacillin (P < 0.05) against both intracellular and extracellular bacteria. The killing activity of levofloxacin against the intracellular population was higher than against the extracellular bacteria (P = 0.1). The frequency of levofloxacin-resistant mutants among surviving bacteria at the end of levofloxacin therapy was similar to that for the wild-type strain. CONCLUSIONS: Intracellular bacteria accounted for the largest proportion of the total inoculum in this model of foreign-body infection. The intracellular activity of an antibiotic seems to be an additional relevant factor in the antibiotic response to these infections.

Clinical features and outcomes of Legionnaires' disease in solid organ transplant recipients.

We identified 14 cases of Legionnaires' disease occurring in 2946 solid organ transplant recipients from 1985 to 2007. Most cases were sporadic and community acquired. The recent introduction of the urinary antigen test has accelerated diagnosis and allows prompt institution of adequate therapy. The overall mortality rate in our series was 14.3%.

Antagonistic effect of rifampin on the efficacy of high-dose levofloxacin in staphylococcal experimental foreign-body infection.

Since levofloxacin at high doses was more active than levofloxacin at conventional doses and was the best therapy alone in a rat model of staphylococcal foreign-body infection, in this study we tested how these differences affect the activities of their respective combinations with rifampin in vitro and in vivo. In vitro studies were performed in the log and stationary phases. By using this model, rifampin at 25 mg/kg of body weight/12 h, levofloxacin at 100 mg/kg/day, levofloxacin at 100 mg/kg/day plus rifampin, levofloxacin at 50 mg/kg/day, levofloxacin at 50 mg/kg/day plus rifampin, or a control treatment was administered for 7 days; and therapy with for levofloxacin at 100 mg/kg/day alone and rifampin alone was prolonged to 14 days. We screened for the appearance of resistant strains. Killing curves in the log phase showed a clear antagonism with levofloxacin at concentrations >or=2x MIC and rifampin and tended to occur in the stationary phase. At the end of 7 days of therapy, levofloxacin at 100 mg/kg/day was the best treatment and decreased the bacterial counts from tissue cage fluid (P < 0.05 compared with the results for groups except those receiving rifampin alone). At the end of 14 days of therapy with levofloxacin at 100 mg/kg/day, levofloxacin at 100 mg/kg/day plus rifampin, and the control treatment, the bacterial counts on the coverslips were 2.24 (P < 0.05 compared with the results with the combined therapy), 3.36, and 5.4 log CFU/ml, respectively. No rifampin or levofloxacin resistance was detected in any group except that receiving rifampin alone. In conclusion, high-dose levofloxacin was the best treatment and no resistant strains appeared; the addition of rifampin showed an antagonistic effect. The efficacy of the rifampin-levofloxacin combination is not significantly improved by the dosage of levofloxacin.

Early mortality in patients with community-acquired pneumonia: causes and risk factors.

The first 48 h of evolution of patients with community-acquired pneumonia (CAP) are critical. The aim of the present study was to determine the frequency, causes and factors associated with early mortality in CAP. Nonimmunocompromised adults hospitalised with CAP were prospectively observed from 1995 to 2005. Early deaths, defined as death due to any cause < or = 48 h after admission, were compared with all patients who survived > 48 h. Furthermore, early deaths were compared with late deaths (patients who died > 48 h) and with survivors. Of 2,457 patients, 57 (2.3%) died < or = 48 h after admission. Overall mortality was 7.7%. The main causes of early mortality were respiratory failure and septic shock/multiorgan failure. Independent factors associated with early deaths were increased age, altered mental status at presentation, multilobar pneumonia, shock at admission, pneumococcal bacteraemia and discordant empiric antibiotic therapy. Currently, early mortality is relatively low and is caused by pneumonia-related factors. It occurs mainly among the elderly and in patients presenting with altered mental status, multilobar pneumonia and septic shock. Pneumococcal bacteraemia and discordant antibiotic therapy, mainly due to lack of coverage against Pseudomonas aeruginosa are also significant risk factors.

Community-acquired bacterial meningitis in cirrhotic patients.

The Hospital Universitari de Bellvitge (Barcelona, Spain) records all cases of bacterial meningitis in a 120-variable database. The characteristics of bacterial meningitis in cirrhotic patients are not well-known, and all cases of community-acquired bacterial meningitis occurring in cirrhotic patients were therefore identified. During 1977-2002, there were 602 episodes of community-acquired bacterial meningitis in adults, of which 29 (4.8%) occurred in cirrhotic patients. Compared to non-cirrhotic patients, there were significant differences in: duration of disease for >4 days at the time of diagnosis; absence of nuchal rigidity; certain aetiologies, e.g., Escherichia coli and Listeria monocytogenes; renal and liver function impairment; relapse of fever; and incidence of relapse and mortality. Overall, bacterial meningitis in cirrhotic patients was associated with a high mortality rate and a large number of complications. A high index of suspicion is necessary because of the frequent absence of meningeal signs. In addition to the classic meningeal pathogens, other aetiologies, including E. coli and L. monocytogenes, should be considered when prescribing empirical therapy.

Outbreak of Legionnaires' disease in immunosuppressed patients at a cancer centre: usefulness of universal urine antigen testing and early levofloxacin therapy.

This report describes an outbreak of Legionnaires' disease in severely immunosuppressed patients hospitalised at a cancer centre. Universal urine antigen testing and early levofloxacin therapy appeared to lower case fatality rates in comparison with previous reports concerning this high-risk population. This diagnostic and therapeutic strategy should be considered when facing a nosocomial outbreak of Legionnaires' disease in immunosuppressed hosts.

Clinical epidemiology and outcomes of peripheral venous catheter-related bloodstream infections at a university-affiliated hospital.

Despite enormous clinical experience of using peripheral vascular catheters, there is still controversy over the incidence and clinical relevance of bloodstream infections caused by these devices and the measures for preventing them. We performed a prospective study to determine the clinical epidemiology and outcomes of nosocomial bloodstream infections caused by short- and mid-line peripheral venous catheters among a group of non-intensive care unit patients. Cases of peripheral venous catheter-related bloodstream infections (PVC-BSIs) were compared to cases of central venous catheter-related bloodstream infections (CVC-BSIs). From October 2001 to March 2003, 150 cases of vascular catheter-related bloodstream infections were identified among 147 patients. Seventy-seven episodes (0.19 cases/1000 patient-days) were PVC-BSIs and 73 episodes (0.18 cases/1000 patient-days) were CVC-BSIs. Compared with CVC-BSIs, patients with PVC-BSIs more often had the catheter inserted in the emergency department (0 vs 42%), had a shorter duration from catheter insertion to bacteraemia (mean: 15.4 vs 4.9 days) and had Staphylococcus aureus (33 vs 53%) more frequently as the causative pathogen. Among patients with PVC-BSIs, catheters inserted in the emergency department had a significantly shorter duration in situ compared with those inserted on hospital wards (mean: 3.7 vs 5.7 days). Patients with PVC-BSIs caused by S. aureus had a higher rate of complicated bacteraemia (7%) and higher overall mortality (27%) than patients with PVC-BSIs caused by other pathogens (0 and 11%, respectively). Bloodstream infections remain underestimated and potentially serious complications of peripheral vascular catheterisation. Targeted interventions should be introduced to minimise this complication.

Bloodstream infection related to catheter connections: a prospective trial of two connection systems.

Bloodstream infections (BSIs) related to central venous catheters (CVCs) and arterial catheters (ACs) are an increasing problem in the management of critically ill patients. Our objective was to assess the efficacy of a needle-free valve connection system (SmartSite), Alaris Medical Systems, San Diego, CA, USA) in the prevention of catheter-related bloodstream infection (CR-BSI). Patients admitted to an intensive care unit were prospectively assigned to have a CVC and AC connected with either a needle-free valve connection system (NFVCS) or a three-way stopcock connection (3WSC). The characteristics of the patients were similar in the two groups. Before manipulation, the NFVCS was disinfected with chlorhexidine digluconate 0.5% alcoholic solution. The 3WSC was not disinfected between use but it was covered with a protection cap. A total of 799 patients requiring the insertion of a multilumen CVC or AC for >48h from 1 April 2002 to 31 December 2003 were included. CR-BSI rates were 4.61 per 1000 days of catheter use in the disinfected NFVCS group and 4.11 per 1000 days of catheter use in the 3WSC group (P=0.59). When CVC-BSIs and AC-BSIs were analysed separately, the rate of CVC-BSI was 4.26 per 1000 days of catheter use in the NFVCS group, compared with 5.27 in the 3WSC group (P=0.4). The incidence rate of AC-BSI was 5.00 per 1000 days of catheter use in the NFVCS group, compared with 2.83 in the 3WSC group (P=0.08). The use of NFVCS does not reduce the incidence of catheter-related bacteraemia. The arterial catheter (AC) is a significant source of infection in critically ill patients.

An insidious nosocomial outbreak due to Salmonella enteritidis.

OBJECTIVES: To investigate an increase in the number of Salmonella enteritidis isolates detected in a large hospital to ascertain whether it was due to a nosocomial source, to identify the mechanisms of transmission, and to institute effective control measures to prevent future episodes. DESIGN: Observational study, survey of all microbiological samples positive for S. enteritidis detected in the hospital, outbreak investigation, and review of the literature. SETTING: A tertiary-care teaching hospital for adults in Barcelona, Spain. RESULTS: During a 7-month period from May to November 1998, we identified 22 inpatients with S. enteritidis infection for whom nosocomial acquisition was strongly suspected. The attack rate was 0.138 per 1,000 patient-days. All affected patients were immunosuppressed and overall mortality was 41% (9 of 22). A sample of a meal cooked in the kitchen was culture positive for S. enteritidis. All isolates shared the same antibiotic susceptibility pattern and all except one shared the same pulsed-field gel electrophoresis (PFGE) pattern, but PFGE could not differentiate between outbreak-related and control strains. After compliance with kitchen hygiene procedures was emphasized and cleansing was intensified, no more cases were detected. CONCLUSIONS: Apparently, sporadic cases of S. enteritidis may be part of an outbreak with a low attack rate. A small but persistent inoculum affecting only individuals with special predisposition for Salmonella infection might account for this. Suspicion should be raised in hospitals and institutions with a highly susceptible population.

An outbreak of carbapenem-resistant Pseudomonas aeruginosa in a urology ward.

OBJECTIVE: To investigate an outbreak of carbapenem-resistant Pseudomonas aeruginosa (CRPA) in a urology ward. METHODS: Patients infected or colonized with CRPA were prospectively identified by daily laboratory surveillance. Routine infection-control measures were reinforced, disinfection protocols were revised, and a surveillance program was set up, analyzing cross-transmission in the nursing ward and environment cultures from urology wards and the operating theater. CRPA isolates from clinical and environment samples were studied by pulsed-field gel electrophoresis (PFGE), following XbaI and SpeI restriction. RESULTS: From February 1998 to September 2000, 59 adult urology patients were colonized or infected by CRPA. All patients had been operated on prior to identification of the CRPA isolate and 79% of these procedures were performed in the same cystoscopy room. No patients had received prior carbapenem therapy. No cross-transmission was detected, and environment cultures from the urology ward and theater were negative except for five samples collected in the cystoscopy room. PFGE identified a single clone in the isolates from different patients and the environment samples. CONCLUSIONS: The PFGE analysis indicated that the CRPA outbreak resulted from the contamination of the cystoscopy room via an unsealed drain. The outbreak ended when the drain was sealed.

[Mechanical ventilation-associated pneumonia and the prevention of stress ulcer. A randomized clinical trial of antacids and ranitidine versus sucralfate]. / Neumonía asociada a ventilación mecánica y profilaxis del ulcus de estrés. Ensayo clínico aleatorizado de antiácidos y ranitidina frente a sucralfato.

BACKGROUND: To study two groups of patients intubated with different prophylaxis of stress gastric ulcer in a prospective randomized trial. The differential effect on gastric pH, gastric colonization and the incidence of pneumonia associated to mechanical ventilation (PMV) were analyzed. METHODS: A prospective randomized study was carried out in two groups of patients: 1) prophylaxis with antacids and H2 blockers (AA+H2) and 2) prophylaxis with sucralfate. Intubated patients without initial respiratory infection were included in the protocol. Periodically gastric aspirations were collected measuring gastric pH and performing semi-quantitative cultures. When pneumonia was suspected bronchial brushing was carried out with telescoped catheter (BBTC) and quantitative culture. RESULTS: Fifty-one patients were studied (n = 51), distributed into 25 in the AA+H2 group and 26 in the sucralfate group. In the first group mean pH was higher (5.3 +/- 1.7) than in the sucralfate group (3.2 +/- 2.1) (p = 0.006). Nosocomial pneumonia (NP) was suspected on 25 occasions: 20 patients were positive for NP, 11 in the AA+H2 group and nine in the sucralfate group with no significant differences being observed. S. aureus, S. pneumoniae and H. influenzae (n = 14) were the etiology of predominant PMV. The global mortality of the group was of 22%. CONCLUSIONS: The prophylaxis of stress ulcers in intubated patients treated with antacids and ranitidine provoked higher gastric pH and an increase in gastric colonization in comparison to that observed with sucralfate. No significant differences were observed in the frequency of pneumonia by PMV diagnosed by BBTC.

[The bacteriological control of TPN mixtures at the Hospital de Bellvitge]. / Control bacteriológico de las mezclas de NPT en el Hospital de Bellvitge.

The complications of sepsis often make it necessary to suspend nutritional therapy. The origin of these is the nutritive mixture as well as the catheter connection and/or point where it has been inserted. The aim of this study is to show the need for bacteriological control of the whole process, in order to evaluate the effectiveness of the methods used, dilucidate the origin of the sepsis and establish an internal quality control. Study of different methods for bacteriological control of the nutritive mixtures, comparing them with the methods used in our Hospital, which is based on systematic culture of the mixtures, the collecting of samples after preparation and prior to perfusing the mixture through the patient, the performing of a further culture control and a bacteriological examination of the catheter. For this purpose, 28,501 nutritive mixtures were studied, corresponding to 1,782 patients. Of these, 185 samples were initially positive (0.65%) and only 59 samples showed positive cultures (0.21%). Of the 6 cases of sepsis discovered and confirmed by haemoculture, 5 corresponded to Enterobacter cloacae and 1 to Klebsiella pneumoniae.