Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR).

This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.

Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline.

The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.

Zigomicetos y zigomicosis en la era de las nuevas terapias antifúngicas / Zygomycetes and zygomycosis in the new era of antifungal therapies

La zigomicosis o mucormicosis es la tercera infección fúngica invasora tras la candidiasis y la aspergilosis. Tradicionalmente se ha consideradouna enfermedad de adquisición comunitaria, pero se está convirtiendo en una infección de frecuente adquisición nosocomial. En los últimosaños, numerosos estudios en instituciones aisladas apuntan a un aumento del número de casos de zigomicosis invasora a raíz de las nuevasterapias antifúngicas e inmunosupresoras, y al aumento de la población inmunodeprimida. Por otro lado, el diagnóstico de la zigomicosismuchas veces es complicado, sobre todo en las formas pulmonares y diseminadas. Uno de los principales problemas que presenta el aislamientode zigomicetos de muestras clínicas en el laboratorio de microbiología es que con frecuencia los resultados tienen una difícil interpretación.Además, el aumento del número de micosis invasoras por hongos resistentes a los antifúngicos ha llevado al desarrollo de nuevasmoléculas con actividad antifúngica y diferentes perfiles de actividad frente a los zigomicetos(AU)

Zygomycosis or mucormycosis is the third most invasive fungal infection after candidiasis and aspergillosis. Traditionally, it has been considereda community-acquired disease, but it is becoming a frequent nosocomial-acquired disease. Recently, several publications from differentinstitutions have reported an increase in the number of cases of invasive zygomycosis as a result of the new antifungal and immunosuppresivetherapies and the emerging immunocompromised population. In addition, the diagnosis of zygomycosis is elusive, mainly in pulmonaryand disseminated forms. One of the main limitations in isolating Zygomycetes from clinical samples is the interpretation of results. The increasingnumber of invasive fungal infections caused by multiresistant fungi has led to the development of new antifungal drugs with variableactivity against Zygomycetes(AU)

[Zygomycetes and zygomycosis in the new era of antifungal therapies]. / Zigomicetos y zigomicosis en la era de las nuevas terapias antifúngicas.

Zygomycosis or mucormycosis is the third most invasive fungal infection after candidiasis and aspergillosis. Traditionally, it has been considered a community-acquired disease, but it is becoming a frequent nosocomial-acquired disease. Recently, several publications from different institutions have reported an increase in the number of cases of invasive zygomycosis as a result of the new antifungal and immunosuppresive therapies and the emerging immunocompromised population. In addition, the diagnosis of zygomycosis is elusive, mainly in pulmonary and disseminated forms. One of the main limitations in isolating Zygomycetes from clinical samples is the interpretation of results. The increasing number of invasive fungal infections caused by multiresistant fungi has led to the development of new antifungal drugs with variable activity against Zygomycetes.

The use of cefotaxime for the treatment of common infections: in vitro, pharmacokinetic and clinical considerations.

The use of the broad-spectrum cephalosporin, cefotaxime, in internal medicine is well-established, particularly in the treatment of moderately severe to severe community- and hospital-acquired infections. It is particularly useful for infections of the lower respiratory tract, urinary and biliary systems, skin and soft tissue, and in serious conditions, such as meningitis, particularly in pediatric patients. Knowledge of the pharmacokinetic and pharmacodynamic properties of cefotaxime supports the view that low dose (1-2 g), low frequency (12-hourly) dosage regimens are applicable to many mild-to-moderately severe infections, including community-acquired pneumonia, caused by susceptible organisms.

Ciprofloxacin in patients with bacteremic infections. The Spanish Group for the Study of Ciprofloxacin.

The efficacy and safety of ciprofloxacin in the treatment of 68 episodes of bacteremia were studied. Patients were treated intravenously (30 cases), orally (13 cases), or with sequential intravenous/oral therapy (25 cases). Intravenous doses ranged from 200 to 400 mg per day and oral doses ranged from 1,000 to 1,500 mg per day. According to the criteria of McCabe and Jackson, 39 cases had nonfatal and 29 had ultimately fatal underlying diseases. The clinical condition of patients at the start of therapy was critical or poor in 40 cases and fair or good in 28. Sixty-four of the 68 episodes of bacteremia were monomicrobial and the remaining four were polymicrobial. The causative micro-organisms were: Escherichia coli (18 episodes), Pseudomonas aeruginosa (13 episodes), Acinetobacter sp. (10 episodes), Salmonella sp. (seven episodes), Enterobacter sp. (six episodes), Proteus sp. (four episodes), Serratia sp. (four episodes), Haemophilus influenzae (three episodes), Klebsiella sp. (three episodes), Staphylococcus aureus (2 episodes), and Morganella morganii (two episodes). Overall clinical efficacy of ciprofloxacin was 94 percent (64 of 68 patients). Bacteremia persisted in four patients (failure rate of 6 percent). Five organisms persisted: Acinetobacter sp. (two patients), P. aeruginosa (one patient), Enterobacter sp. (one patient), and Serratia sp. (one patient). Side effects were phlebitis associated with intravenous administration (four cases), dizziness (four cases), and superinfection (six cases). Superinfecting organisms and sites were as follows: Enterococcus faecalis, wound (2 cases); Candida sp., urinary tract infection (one case); Acinetobacter anitratus (ciprofloxacin resistant), urinary tract infection (one case); Staphylococcus epidermidis, blood (one case); and Clostridium perfringens, blood (one case). Ciprofloxacin administered either intravenously, orally, or intravenously followed by the oral route is effective therapy in the treatment of severe bacteremic infections.

[Evaluation of ciprofloxacin for the treatment of severe bacterial infections]. / Evaluación de la ciprofloxacina en el tratamiento de infecciones bacterianas graves.

The results of efficacy and safety of ciprofloxacin administered by parenteral and oral route in the treatment of severe infections-particularly, osteomyelitis and bacteremia-due to gram-negative bacilli are studied in the present work. The group consisted of 34 patients, there were 25 men and 9 women, whose age ranged from 5 to 84 years. Two patients were excluded from the study and did not enter in the efficacy analysis, although they accounted for the evaluation of incidence of side effects. Ten patients presented osteomyelitis, 16 patients had bacteremia (one of them, with endocarditis), and six patients suffered from other types of infection (one of them had meningitis). All patients recovered or presented clinical improvement with the treatment, except three of them, which accounted for a response rate of 90.6%. In 28 of the 32 evaluable cases, microbiologic eradication was achieved (eradication rate, 87.5%). Infection due to Pseudomonas aeruginosa persisted or recurred in three patients with chronic osteomyelitis; in two of them, the strain become resistant to ciprofloxacin, and in the third patient, the results of cultures persisted positive along the whole course, thus, the eradication of the microorganism was not achieved. One woman presented bacteremia due to Acinetobacter which persisted despite antibiotic therapy. Side effects were mild and obliged to withdraw the treatment in two cases (dizziness). Ciprofloxacin is a new fluoroquinolone that is easily administered by parenteral and oral route. In the present study, it has revealed as safe and highly efficacious, even in particularly severe or resistant bacterial infections.