Recommendations for antibiotic selection for severe nosocomial infections.

Severe infection and its evolution to sepsis are becoming more prevalent every day and are among the leading causes of critical illness and mortality. Proper management is crucial to improve prognosis. This document addresses three essential points that have a significant impact on this objective: a) early recognition of patients with sepsis criteria, b) identification of those patients who suffer from an infection and have a high risk of progressing to sepsis, and c) adequate selection and optimization of the initial antimicrobial treatment.

[Drug treatment of native valve infective endocarditis in patients not addicted to parenteral drugs]. / Tratamiento médico de la endocarditis infecciosa sobre válvula nativa en pacientes no adictos a drogas por vía parenteral.

Infectious endocarditis is an infection that is characterized by the presence of microorganisms in dense populations in vegetating lesions in the endocardium. Because phagocyte penetration to the interior of the vegetation is practically impossible, to cure infectious endocarditis, high doses of bactericidal antibiotics are administered, usually intravenously and for a long duration. In this article, antibiotic treatment is reviewed, depending on the isolated microorganism and in cases where necessary, treatment is initiated in an empirical manner. Once the microorganism was isolated, the recommended guidelines for antibiotic treatment have gone through some variations in recent years, due to the changing pattern of antibiotic sensitivity of some microorganisms, to the point of finding ourselves on occasion without an effective treatment (e.g. multiresistant enterococci). In addition, these variations are due to the introduction of new antibiotics that allow, in special cases, for the treatment to be administered on an outpatient basis. Using anticoagulation in infectious endocarditis is still considered controversial. In general, only patients having cardiac valvular prostheses seem to benefit from its use.

[Nosocomial infective endocarditis in patients without hear prosthesis]. / Endocarditis infecciosa nosocomial en pacientes sin prótesis cardíaca.

BACKGROUND: Infective endocarditis is a complication of nosocomial bacteremia and is associated with a high mortality rate. The objective of the present study was to know the clinical and microbiological characteristics of nosocomial endocarditis (NE) diagnosed in a general hospital in a five-year period. PATIENTS AND METHODS: Twenty-one patients diagnosed of NE following Durack's criteria at Juan Canalejo Hospital from January 1990 to January 1995 were studied. Endocarditis in patients with cardiac valve prosthesis were excluded. RESULTS: NE represented 12% of the total endocarditis cases diagnosed during the study period. The mean age of patients was 52.6 years (range: 17-79 years) and male accounted for 81% of cases. NE was related to an intravascular catheter in 85.7% of cases, whereas a urinary source was found in 14.3%. Staphylococcus aureus was the microorganism recovered most frequently (62%), followed by Staphylococcus epidermidis (20%), which was always associated with intravascular catheters. Left valve involvement predominated (76.2%) and the involvement of right cavities was detected exclusively in patients with an intravascular catheter as known source of NE. Transoesophageal echocardiography detected vegetations in 19% of cases in which transthoracic echography failed to identify them. Surgery was required by 28.5% of patients and its indication was always congestive heart failure refractory to medical treatment. The overall mortality rate was 28.5%, compared with 26.8% in community acquired endocarditis. Two patients with Candida spp. endocarditis were not treated surgically and the outcome was satisfactory. CONCLUSIONS: Nosocomial endocarditis represent a significant percentage of endocarditis once endocarditis on prosthetic cardiac valves has been excluded. To remark Staphylococcus spp. in the etiology of this entity, the intravascular catheter as risk factor, and left cavities as location. Transoesophageal echocardiography is of great diagnostic usefulness. In contrast with reports in literature, the mortality rate in our series was similar to that of community endocarditis.

Abscesos cerebrales múltiples en paciente con aneurisma del tabique interauricular silente y shunt / Multiple brain abscesses in a patient with silent aneurysm of the interatrial septum and shunt

Se presenta el caso de un paciente con abscesos cerebrales múltiples, con un antecedente de meningitis purulenta y el hallazgo de un aneurisma de tabique interauricular silente con shunt derecha - izquierda. Si bien en la edad pediátrica se encuentra una gran asociación entre la presencia de malformaciones cardíacas con shunt y los abscesos cerebrales, la mayoría de la bibliografía revisada de comunicaciones interauriculares y shunts silentes derecha-izquierda en la población adulta hacen referencia a la producción de fenómenos embólicos cerebrales de tipo isquémico, pero muy pocos la señalan como posible vía de escape al filtro pulmonar de forma que una bacteriemia pueda producir embolismos sépticos a nivel cerebral.Ante la presencia de abscesos cerebrales múltiples no debemos olvidar en el proceso diagnóstico el realizar una búsqueda dirigida, ya que la presencia de malformaciones cardíacas con shunt derecha - izquierda puede ser la vía de acceso de la infección al parénquima cerebral. (AU)