[Antimicrobial stewardship program during the COVID-19 pandemic]. / Programa de optimización del uso de antimicrobianos durante la pandemia de COVID-19.

In spite of the low frequency of COVID-19 associated bacterial coinfections, the rate of empiric antibiotic use varies between 70% and 90%. The primary objective of this study was to evaluate the impact of an antimicrobial stewardship program (ASP) on COVID-19 patients. The study design was an interrupted time series, assessing prevalence of antibiotic use, adequacy of treatment and antimicrobial consumption in adult patients hospitalized with COVID before the COVID-ASP implementation in June 2020, and on three subsequent periods (P2 in August 2020, P3 in October 2020 and P4 in June 2021). One hundred and one patients were included. Moderate and severe disease was more frequent in P2, P3, and P4 periods (p < 0.001). After the implementation we observed a significant reduction on ATM use (61% vs. 41% vs. 31.1% vs. 8.1%, p < 0.001), and macrolid combination therapy (17.3% vs. 19.2% vs. 10.8% vs. 1.4%, p = 0.03), and an increase of adequate use (37.5% vs. 46.9% vs. 69.9% vs. 66.6%, p = 0.039). Antimicrobial consumption by period in days of therapy (DOT)/1000 patient-day was 347.9 vs. 272.8 vs. 134.29 vs. 43.6 (p <0.001). We did not find any difference in intensive care unit transfer or mortality. COVID-ASP implementation was an effective strategy to reduce antimicrobial consumption and optimize antibiotic indications without affecting morbidity or mortality.

A pesar de la baja frecuencia de coinfecciones bacterianas asociadas al COVID-19, la tasa de uso de antibióticos (ATB) empíricos varía entre 70 y 90%. El objetivo primario del estudio fue evaluar el impacto de la implementación de un programa de optimización de antimicrobianos en pacientes con COVID-19 (PROA-COVID). Se realizó un estudio prospectivo de serie de tiempo interrumpida. Se evaluó la prevalencia, adecuación y consumo de ATB en adultos internados con COVID previo a la implementación del PROA-COVID (P1, junio 2020) y en tres períodos posteriores (P2 en agosto 2020, P3 en octubre 2020 y P4 en junio 2021). Se incluyeron 301 pacientes. Las formas clínicas moderadas-graves fueron más frecuentes en los P2, 3 y 4 (p < 0.001). La implementación del programa mostró una disminución significativa del uso de ATB (61% vs. 41% vs. 31.1% vs. 8.1%, p < 0.001), de la indicación de tratamiento combinado con macrólidos (17.3% vs. 19.2% vs. 10.8% vs. 1.4%, p = 0.03) y aumento del uso adecuado (37.5% vs. 46.9% vs. 69.9% vs. 66.6%, p = 0.039). El consumo de ATB en DDT (días de tratamiento) totales/1000 días paciente fue: 347.9 vs. 272.8 vs. 134.3 vs. 43.6 (p < 0.001). No hubo diferencias significativas en el pase a unidades de cuidados críticos ni en la mortalidad. La implementación del PROA-COVID fue una estrategia efectiva para reducir el uso de antibióticos y optimizar sus indicaciones sin impacto en la morbimortalidad.

Programa de optimización del uso de antimicrobianos durante la pandemia de COVID-19 / Antimicrobial stewardship program during the COVID-19 pandemic

Resumen A pesar de la baja frecuencia de coinfecciones bacterianas asociadas al COVID-19, la tasa de uso de antibióticos (ATB) empíricos varía entre 70 y 90%. El objetivo primario del estudio fue evaluar el impacto de la implementación de un programa de optimización de antimicrobianos en pacientes con COVID-19 (PROA-COVID). Se realizó un estudio prospectivo de serie de tiempo interrumpida. Se evaluó la prevalencia, adecuación y consumo de ATB en adultos internados con COVID previo a la implementación del PROA-COVID (P1, junio 2020) y en tres períodos posteriores (P2 en agosto 2020, P3 en octubre 2020 y P4 en junio 2021). Se incluyeron 301 pacientes. Las formas clínicas moderadas-graves fueron más frecuentes en los P2, 3 y 4 (p < 0.001). La implementación del programa mostró una disminución significativa del uso de ATB (61% vs. 41% vs. 31.1% vs. 8.1%, p < 0.001), de la indicación de tratamiento combinado con macrólidos (17.3% vs. 19.2% vs. 10.8% vs. 1.4%, p = 0.03) y aumento del uso adecuado (37.5% vs. 46.9% vs. 69.9% vs. 66.6%, p = 0.039). El consumo de ATB en DDT (días de tratamiento) totales/1000 días paciente fue: 347.9 vs. 272.8 vs. 134.3 vs. 43.6 (p < 0.001). No hubo diferencias significativas en el pase a unidades de cuidados críticos ni en la mortalidad. La implementación del PROA-COVID fue una estrategia efectiva para reducir el uso de antibióticos y optimizar sus indicaciones sin impacto en la morbimortalidad.

Abstract In spite of the low frequency of COVID-19 associated bacterial coinfections, the rate of empiric an tibiotic use varies between 70% and 90%. The primary objective of this study was to evaluate the impact of an antimicrobial stewardship program (ASP) on COVID-19 patients. The study design was an interrupted time series, assessing prevalence of antibiotic use, adequacy of treatment and antimicrobial consumption in adult patients hospitalized with COVID before the COVID-ASP implementation in June 2020, and on three subsequent periods (P2 in August 2020, P3 in October 2020 and P4 in June 2021). One hundred and one patients were included. Moderate and severe disease was more frequent in P2, P3, and P4 periods (p < 0.001). After the implementation we observed a significant reduction on ATM use (61% vs. 41% vs. 31.1% vs. 8.1%, p < 0.001), and macrolid combination therapy (17.3% vs. 19.2% vs. 10.8% vs. 1.4%, p = 0.03), and an increase of adequate use (37.5% vs. 46.9% vs. 69.9% vs. 66.6%, p = 0.039). Antimicrobial consumption by period in days of therapy (DOT)/1000 patient-day was 347.9 vs. 272.8 vs. 134.29 vs. 43.6 (p<0.001). We did not find any difference in intensive care unit transfer or mortality. COVID-ASP implementation was an effective strategy to reduce antimicrobial consump tion and optimize antibiotic indications without affecting morbidity or mortality.

Reumatólogos frente al papeleo: evaluación de la carga administrativa en un Servicio de Reumatología / Rheumatologists versus paperwork: assessment of administrative burden in a Rheumatology Service

Introducción: los resúmenes de historia clínica (RHC), confeccionados por reumatólogos, los solicitan los pacientes para realizar diversos trámites. Su incumplimiento afecta el acceso a las prestaciones sanitarias e implica que los médicos destinen tiempo a un requisito puramente burocrático. Los objetivos de este estudio fueron: determinar la frecuencia de RHC solicitados y realizados en nuestro Servicio durante un semestre y el tiempo dedicado a dicha tarea; describir los motivos de las solicitudes y las características de los solicitantes. Materiales y métodos: se incluyeron todos los pacientes que solicitaron ≥1 RHC en el último semestre de 2019. Se registraron características sociodemográficas, enfermedad de base y motivos de solicitud. Se consideró, como parámetro de comparación, una duración predeterminada de 15 minutos por consulta médica. Resultados: se registraron 103 solicitantes de RHC en 3159 citas programadas en 152 días. Se realizaron 144 RHC (0,95/día). Un 18% solicitó uno nuevo en el mismo intervalo. El tiempo promedio para la confección de cada resumen fue de 75 minutos. El tiempo total dedicado a estas tareas administrativas en el semestre evaluado fue el equivalente a 720 citas potenciales, aproximadamente un 20% de los turnos programados ofrecidos. La mayoría se emitió para solicitar medicamentos crónicos, principalmente para artritis reumatoidea, y con cobertura médica pública. Conclusiones: el tiempo destinado a confeccionar RHC por motivos administrativos fue el equivalente a un aumento potencial de más del 20% de las citas médicas.

Introduction: medical history summaries (MHS) issued by rheumatologists are requested by patients for various procedures. Not completing them denies access to health benefits, this implies that physicians spend time on a purely bureaucratic requirement. The objectives were: to determine the frequency of MHS requested and issued in our service during a semester and the time dedicated to them; to describe the reasons for the request and the characteristics of the applicants. Materials and methods: all patients who request ≥1 MHS in the last semester of 2019 were included. Sociodemographic characteristics, underlying disease and reasons for request were recorded. As a comparison measure, a predetermined duration of 15 minutes per medical appointment was expected. Results: 103 MHS applicants in 3159 scheduled appointments in 152 days. 144 MHS were performed (0.95/day). 18% requested a new one in the same interval. The average time in the preparation of a MHS was 75 minutes. The total time spent on these during the evaluated semester was equivalent to 720 potential appointments, approximately 20% of scheduled appointments that were granted. Most were issued to request chronic medications, mainly in rheumatoid arthritis and public health care. Conclusions: the time spent to prepare MHS for administrative reasons was comparable to a potential increase of more than 20% in medical appointments.

Impacto de la pandemia por SARS-CoV-2 en la formación de los alumnos de la Carrera de Médico Especialista en Reumatología / Impact of the SARS-CoV-2 pandemic on a group of Rheumatology trainees of Argentina

Introducción: en 2020, la rápida evolución de la pandemia por SARS-CoV-2 desencadenó una emergencia sanitaria que generó una importante reorganización del sistema de salud, lo que llevó a la discontinuación y posterior adecuación de los sistemas de formación. El objetivo de este estudio fue describir el impacto de la pandemia en un grupo de reumatólogos en formación en la Ciudad Autónoma de Buenos Aires. Materiales y métodos: se envió una encuesta online por correo electrónico a los alumnos de la Carrera de Especialista en Reumatología de la Sociedad Argentina de Reumatología y de la Universidad de Buenos Aires. Incluyó 24 preguntas relacionadas con el impacto de la pandemia en diferentes aspectos de la formación y las nuevas estrategias educativas implementadas. Resultados: de 114 alumnos contactados, respondieron 79 (69,3%). Aproximadamente el 90% indicó que su formación se afectó. Un 46% consideró que la práctica médica y la actividad académica se comprometieron por igual y el 45% solo la práctica médica. Un 50% realizó tareas no relacionadas con su formación. El 57% suspendió temporalmente la asistencia a su centro. También informaron una reducción del 55% (DE 18,6) de las actividades relacionadas con la consulta. Conclusiones: la pandemia por SARS-CoV-2 afectó a los estudiantes de Reumatología al limitar sus actividades prácticas y académicas, y por deber realizar tareas ajenas a su formación en más de la mitad de los casos.

Introduction: in 2020, the rapid evolution of the SARS-CoV-2 pandemic triggered a health emergency, generating an important heath system reorganization which led to the discontinuation and subsequent adaptation of training systems. The objective was to describe the pandemic impact on a group of rheumatology trainees in Buenos Aires, Argentina. Materials and methods: an online survey was sent through e-mail to rheumatology specialist course trainees of Argentine Society of Rheumatology and University of Buenos Aires. It included 24 close-ended questions about the pandemic impact on different aspects of rheumatology training and the new implemented educational response strategies. Results: from 114 trainees contacted, 79 (69.3%) responded. Approximately 90% indicated that their rheumatology training was affected. Forty-six percent thought that medical practice and academic activity were equally affected and 45% that only medical practice was compromised. About 50% reported that they had to perform tasks unrelated to their training. Fifty-seven percent discontinued temporarily the training site attendance. Participants reported a mean reduction of 55% (SD 18.6) of activities related to patient care. Conclusions: the SARS-CoV-2 pandemic affected rheumatology trainees, by limiting their practical and academics activities, and having to perform tasks unrelated to their training in more than a half.

[Multicenter study of COVID-19 incidence and determinants in Argentinian physicians]. / Estudio multicéntrico de incidencia y determinantes de COVID-19 en médicos de Argentina.

BACKGROUND: Information about COVID infection in physicians is limited. This knowledge would allow the implementation of actions to reduce its impact. The objective was determining the incidence of SARSCoV-2 infection in physicians from health institutions in Argentina, its characteristics, and associated factors. METHODS: We conducted a multicenter prospective / retrospective cohort study with nested case-control study. Physicians active at the beginning of the pandemic were included, those on leave due to risk factors were excluded. The incidence of confirmed cases was estimated. We conducted bivariate analyses with various factors and used those significant in a logistic regression. RESULTS: Three hundred and forty three physicians with COVID-infection from 8 centers were included. The incidence of disease was 12.1% and that of global absenteeism related to COVID, 34.1%. Almost 70% of close contacts were work-related. In the multivariate analysis living in Autonomous City of Buenos Aires (CABA) (OR 0.19, p = 0.01), working in high-risk areas (OR 0.22, p = 0.01) and individual transportation (OR 0, 34, p = 0.03) reduced the risk of COVID. The odds of infection increased 5.6 times (p = 0.02) for each close contact isolation. DISCUSSION: The number of close contact isolation increased considerably the risk of infection. Living in Buenos Aires City, individual transportation and working in high-risk areas reduced it. Given the high frequency of close contact in the workplace, we strongly recommend the reinforcement of prevention measures in rest areas and non-COVID-wards.

Introducción: La información sobre COVID en médicos es limitada. Su conocimiento permitiría implementar acciones para reducir su impacto. El objetivo general fue determinar la incidencia de infección por SARS-CoV-2 en médicos de instituciones de salud de Argentina, sus características y factores asociados. Materiales y Métodos: Se realizó un estudio multicéntrico de cohorte prospectiva/retrospectiva con estudio de casos-controles anidado. Se incluyeron médicos activos al inicio de la pandemia no exceptuados por riesgo. Se estimó incidencia de casos confirmados. Se compararon factores asociados en casos y controles y se creó un modelo de regresión logística con las variables significativas del análisis bivariado. Resultados: Se incluyeron 343 médicos con COVID de 8 centros. La incidencia de la enfermedad fue de 12.1% y la de ausentismo global relacionado a COVID, de 34.1%. El 70% de los contactos estrechos fueron laborales. En el análisis multivariado de casos y controles, la residencia en la Ciudad Autónoma de Buenos Aires (OR 0.19, p = 0.01), el trabajo en áreas de alto riesgo (OR 0.22, p = 0.01) y vehículo individual (OR 0.34, p = 0.03) redujeron el riesgo de COVID. El odds de enfermar aumentó 4.6 veces (p = 0.02) por cada aislamiento por contacto estrecho. Discusión: El riesgo de enfermar aumentó considerablemente con cada aislamiento por contacto estrecho. La residencia en Ciudad Autónoma, el traslado en vehículo individual y el trabajo en áreas de alto riesgo lo redujeron. Dada la alta frecuencia de contactos estrechos en el ámbito laboral recomendamos reforzar las medidas de prevención en áreas de descanso y no COVID.

Estudio multicéntrico de incidencia y determinantes de COVID-19 en médicos de Argentina / Multicenter study of COVID-19 incidence and determinants in Argentinian physicians

Resumen Introducción: La información sobre COVID en médicos es limitada. Su conocimiento permitiría implementar acciones para reducir su impacto. El objetivo general fue determinar la incidencia de infección por SARS-CoV-2 en médicos de instituciones de salud de Argentina, sus características y factores aso ciados. Materiales y Métodos: Se realizó un estudio multicéntrico de cohorte prospectiva/retrospectiva con estudio de casos-controles anidado. Se incluyeron médicos activos al inicio de la pandemia no exceptuados por riesgo. Se estimó incidencia de casos confirmados. Se compararon factores asociados en casos y controles y se creó un modelo de regresión logística con las variables significativas del análisis bivariado. Resultados: Se incluyeron 343 médicos con COVID de 8 centros. La incidencia de la enfermedad fue de 12.1% y la de ausentismo global relacionado a COVID, de 34.1%. El 70% de los contactos estrechos fueron laborales. En el análisis multivariado de casos y controles, la residencia en la Ciudad Autónoma de Buenos Aires (OR 0.19, p = 0.01), el trabajo en áreas de alto riesgo (OR 0.22, p = 0.01) y vehículo individual (OR 0.34, p = 0.03) redujeron el riesgo de COVID. El odds de enfermar aumentó 4.6 veces (p = 0.02) por cada aislamiento por contacto estrecho. Discusión: El riesgo de enfermar aumentó considerablemente con cada aislamiento por contacto estrecho. La residencia en Ciudad Autónoma, el traslado en vehículo individual y el trabajo en áreas de alto riesgo lo redujeron. Dada la alta frecuencia de contactos estrechos en el ámbito laboral recomendamos reforzar las medidas de prevención en áreas de descanso y no COVID.

Abstract Background: Information about COVID infection in physicians is limited. This knowledge would allow the implementation of actions to reduce its impact. The objective was determining the incidence of SARS-CoV-2 infection in physicians from health institutions in Argentina, its characteristics, and associated factors. Methods: We conducted a multicenter prospective / retrospective cohort study with nested case-control study. Physicians active at the beginning of the pandemic were included, those on leave due to risk factors were excluded. The incidence of confirmed cases was estimated. We conducted bivariate analyses with various factors and used those significant in a logistic regression. Results: Three hundred and forty three physicians with COVID-infection from 8 centers were included. The incidence of disease was 12.1% and that of global absenteeism related to COVID, 34.1%. Almost 70% of close contacts were work-related. In the multivariate analysis living in Autonomous City of Buenos Aires (CABA) (OR 0.19, p = 0.01), working in high-risk areas (OR 0.22, p = 0.01) and individual transportation (OR 0, 34, p = 0.03) reduced the risk of COVID. The odds of infection increased 5.6 times (p = 0.02) for each close contact isolation. Discussion: The number of close contact isolation increased considerably the risk of infection. Living in Buenos Aires City, individual transpor tation and working in high-risk areas reduced it. Given the high frequency of close contact in the workplace, we strongly recommend the reinforcement of prevention measures in rest areas and non-COVID-wards.

Demora en el inicio del tratamiento biológico o sintético dirigido en pacientes con artritis reumatoidea y factores asociados a la misma / Delayed onset of biologic or targeted synthetic dmards in rheumatoid arthritis patients and associated factors

Introducción: el objetivo del tratamiento de la artritis reumatoidea (AR) es la remisión o baja actividad de la enfermedad. En aquellos pacientes que no logran dicho objetivo con drogas modificadoras de la enfermedad sintéticas convencionales (DMARsc), se indican los agentes biológicos (DMARb) o sintéticos dirigidos (DMARsd). El intervalo de tiempo entre la indicación y hasta que el paciente recibe la primera dosis es variable. Objetivos: describir el tiempo de demora y los motivos relacionados entre la indicación de DMARb o DMARsd y la administración de la primera dosis. Materiales y métodos: estudio observacional, analítico, retrospectivo. Se revisaron historias clínicas de pacientes con diagnóstico de AR, a quienes se les indicó DMARb o DMARsd. Se registraron datos sociodemográficos y características de la enfermedad. Respecto de la indicación de DMARb o DMARsd, se consignó: fecha de indicación, fecha en que el paciente recibió la primera dosis en forma efectiva y motivo de la demora. Resultados: se incluyeron 102 pacientes. La mediana de demora desde la indicación de la droga hasta que el paciente recibió la primera dosis fue de 240 días (RIC 113-504). El principal motivo de demora fue de índole burocrática (47%). Los pacientes con baja actividad de la enfermedad obtuvieron la medicación en menor tiempo (113 días) respecto de aquellos con actividad moderada (242 días) y alta actividad (332 días); p=0,01. Los pacientes en los cuales la demora fue por causas burocráticas, presentaron menor nivel de educación (60% vs 17% con educación superior) y residencia en la Provincia de Buenos Aires (58% vs 31% con residencia en la Ciudad Autónoma de Buenos Aires), siendo estas asociaciones estadísticamente significativas. Conclusiones: la mediana en la demora para el inicio de DMARb o DMARsd fue de aproximadamente 8 meses. El motivo principal de este retraso fue de índole burocrática, evidenciándose la misma con mayor frecuencia en aquellos con menor nivel educativo y en los residentes en la Provincia de Buenos Aires.

Introduction: the goal of rheumatoid arthritis (RA) treatment is to obtain remission or low activity of the disease. In those patients who did not achieve this objective with conventional treatment, biologic or targeted synthetic disease-modifying antirheumatic drugs (bDMARD or tsDMARD, respectively) are indicated. The period of time between the prescription of these medications and its administration is variable. Objectives: to describe the delay time between the prescription of a bDMARD or tsDMARD and the administration of the first dose, and its related reasons. Materials and methods: observational, analytical, retrospective study. Medical records of patients with a diagnosis of RA who were prescribed a bDMARD or tsDMARD were reviewed. Sociodemographic data and characteristics of the disease were recorded. Regarding the indication of bDMARDs or tsDMARs, the following data was collected: prescription date, date on which the patient received the first effective dose and reason for the delay. Results: 102 patients were included. The median delay time from the drug prescription until the patient received the first dose was 240 days (IQR 113-504). The main reason for delay was of bureaucratic nature (47%). Patients with low disease activity obtained the medication with a shorter delay (113 days) compared to those with moderate activity (242 days) and high activity (332 days); p=0.01. Patients with a delay related to bureaucratic causes, presented a lower level of education (60% vs 17% with higher education) and residence in the Province of Buenos Aires (58% vs 31% with residence in Autonomous City of Buenos Aires), and these differences were statistically significant. Conclusions: the median delay time to onset of bDMARDs or tsDMARDs was approximately 8 months. The main reason for this delay was of bureaucratic nature, being more frequent in those with lower educational level and residence in the Province of Buenos Aires.

Demora en el inicio del tratamiento biológico o sintético dirigido en pacientes con artritis reumatoidea y factores asociados a la misma / Delayed onset of biologic or targeted synthetic dmards in rheumatoid arthritis patients and associated factors

Introducción: el objetivo del tratamiento de la artritis reumatoidea (AR) es la remisión o baja actividad de la enfermedad. En aquellos pacientes que no logran dicho objetivo con drogas modificadoras de la enfermedad sintéticas convencionales (DMARsc), se indican los agentes biológicos (DMARb) o sintéticos dirigidos (DMARsd). El intervalo de tiempo entre la indicación y hasta que el paciente recibe la primera dosis es variable. Objetivos: describir el tiempo de demora y los motivos relacionados entre la indicación de DMARb o DMARsd y la administración de la primera dosis. Materiales y métodos: estudio observacional, analítico, retrospectivo. Se revisaron historias clínicas de pacientes con diagnóstico de AR, a quienes se les indicó DMARb o DMARsd. Se registraron datos sociodemográficos y características de la enfermedad. Respecto de la indicación de DMARb o DMARsd, se consignó: fecha de indicación, fecha en que el paciente recibió la primera dosis en forma efectiva y motivo de la demora. Resultados: se incluyeron 102 pacientes. La mediana de demora desde la indicación de la droga hasta que el paciente recibió la primera dosis fue de 240 días (RIC 113-504). El principal motivo de demora fue de índole burocrática (47%). Los pacientes con baja actividad de la enfermedad obtuvieron la medicación en menor tiempo (113 días) respecto de aquellos con actividad moderada (242 días) y alta actividad (332 días); p=0,01. Los pacientes en los cuales la demora fue por causas burocráticas, presentaron menor nivel de educación (60% vs 17% con educación superior) y residencia en la Provincia de Buenos Aires (58% vs 31% con residencia en la Ciudad Autónoma de Buenos Aires), siendo estas asociaciones estadísticamente significativas. Conclusiones: la mediana en la demora para el inicio de DMARb o DMARsd fue de aproximadamente 8 meses. El motivo principal de este retraso fue de índole burocrática, evidenciándose la misma con mayor frecuencia en aquellos con menor nivel educativo y en los residentes en la Provincia de Buenos Aires.

Introduction: the goal of rheumatoid arthritis (RA) treatment is to obtain remission or low activity of the disease. In those patients who did not achieve this objective with conventional treatment, biologic or targeted synthetic disease-modifying antirheumatic drugs (bDMARD or tsDMARD, respectively) are indicated. The period of time between the prescription of these medications and its administration is variable. Objectives: to describe the delay time between the prescription of a bDMARD or tsDMARD and the administration of the first dose, and its related reasons. Materials and methods: observational, analytical, retrospective study. Medical records of patients with a diagnosis of RA who were prescribed a bDMARD or tsDMARD were reviewed. Sociodemographic data and characteristics of the disease were recorded. Regarding the indication of bDMARDs or tsDMARs, the following data was collected: prescription date, date on which the patient received the first effective dose and reason for the delay. Results: 102 patients were included. The median delay time from the drug prescription until the patient received the first dose was 240 days (IQR 113-504). The main reason for delay was of bureaucratic nature (47%). Patients with low disease activity obtained the medication with a shorter delay (113 days) compared to those with moderate activity (242 days) and high activity (332 days); p=0.01. Patients with a delay related to bureaucratic causes, presented a lower level of education (60% vs 17% with higher education) and residence in the Province of Buenos Aires (58% vs 31% with residence in Autonomous City of Buenos Aires), and these differences were statistically significant. Conclusions: the median delay time to onset of bDMARDs or tsDMARDs was approximately 8 months. The main reason for this delay was of bureaucratic nature, being more frequent in those with lower educational level and residence in the Province of Buenos Aires.

Validation and adaptation of the Spanish version of the systemic lupus activity questionnaire (S-SLAQ) in an Argentinean population.

OBJECTIVES: To validate the systemic lupus activity questionnaire (SLAQ) in Spanish language. METHODS: The SLAQ questionnaire was translated and adapted in Spanish. Consecutive SLE patients from 8 centers in Argentina were included. A rheumatologist completed a Systemic Lupus Activity Measure (SLAM), Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)-2K, and a physician's assessment. Reliability was assessed by internal consistency (Cronbach's alpha), stability by test-retest reliability (intraclass correlation coefficient), and construct validity by evaluating the correlation with clinically relevant scores. Sensitivity and specificity for clinically significant disease activity (SLEDAI ≥6) of different S-SLAQ cut-off points were evaluated. RESULTS: We included 97 patients ((93% female, mean age: 40 years (SD14.7)). Internal consistency was excellent (Cronbach's alpha = 0.84, p < 0.001), and the intraclass correlation coefficient was 0.95 (p < 0.001). Mean score of S-SLAQ was 8.2 (SD 7.31). Correlation of S-SLAQ was moderate with Patient NRS (r= 0.63 p< 0.001), weak with SLAM-no lab (r = 0.42, p <0.001) and SLAM (r = 0.38, p < 0.0001), and very weak with SLEDAI-2K (r = 0.15, p =0.1394). Using the S-SLAQ cutoff of five points, the sensitivity was 72.2% and specificity was 37.9%, for clinically significant disease activity. CONCLUSIONS: The S-SLAQ showed good validity and reliability. A good correlation, similar to the original instrument, was observed with patient´s global disease activity. No correlation was found between S-SLAQ and gold standard disease activity measures like SLEDAI-2K and SLAM. The S-SLAQ cutoff point of 5 showed a good sensitivity to identify the active SLE population and therefore could be an appropriate screening instrument for disease activity in clinical and epidemiological studies.

Validation of the HAQ-UP-A (Health Assessment Questionnaire-Upper Limbs-Argentine Version) in Patients With Rheumatoid Arthritis. / Validación del HAQ-UP-A (Health Assessment Questionnaire-Upper limbs Argentine version) en pacientes con artritis reumatoide.

HAQ is considered the gold standard for the evaluation of functional capacity in patients with rheumatoid arthritis (RA), even though it does not focus on any particular anatomical region. With the objective of assessing functional disability of the hand in elderly patients with osteoarthritis, Baron et al. used a modified version of the HAQ which was calculated as the mean value for the categories mostly involving the upper extremities and named it 'HAQ-UP'. This instrument has not been validated in patients with RA. OBJECTIVE: To validate HAQ-UP-Argentine version in patients with RA. METHODS: Cross-sectional study. Consecutive patients ≥18years with diagnosis of RA (ACR/EULAR 2010) were included. Socio-demographic data and RA characteristics were recorded. Questionnaires were administered: HAQ-A, HAQ-UP-A, FIHOA, Quick-DASH. The reproducibility of the questionnaire was assessed. RESULTS: A total of 100 patients were included, 83% women, mean age 57.9years (SD 11.6). Cronbach's alpha test was 0.94. The intra-item correlation did not show redundant questions. HAQ-UP-A showed excellent correlation with HAQ-A (r=.93); FIHOA (r=.89) and Quick-DASH (r=.91). It also showed good correlation with DAS28-ESR (r=.68) and other composite disease activity indices as well as with other parameters of the disease. There was no correlation between HAQ-UP-A and disease duration. The reproducibility of the questionnaire was 0.82. Multiple linear regression adjusted for age and sex showed patient global VAS as the main determinant of HAQ-UP-A, followed by the presence of morning stiffness. CONCLUSION: HAQ-UP-A was found to be reliable, valid and reproducible in patients with RA, representing a useful tool for the evaluation of the functional capacity of the upper limbs in these patients.

[Multicenter study of adherence to guidelines on surgical prophylaxis and the determinants of non-adherence in ArgentinaEstudo multicêntrico sobre a adesão a diretrizes de profilaxia cirúrgica e seus determinantes na Argentina]. / Estudio multicéntrico de adherencia a guías de profilaxis quirúrgica y sus determinantes en Argentina.

OBJECTIVE: Evaluate the level of adherence to guidelines on surgical prophylaxis in health facilities in Argentina and the determinants of non-adherence. METHODS: Cross-sectional multicenter study in 35 centers in Argentina. The level of adherence to guidelines and the forms of non-adherence were determined and these were compared based on the characteristics of the indicated antibiotic, anesthesiologist, surgery, and facility, as well as patient age. An adjusted logistic regression model was used. RESULTS: A total of 1,083 surgical procedures were reviewed. Adherence to guidelines was 67%. The most frequent forms of non-adherence were: incorrect antibiotic (28.9%), unnecessary prophylaxis (25.5%), and prolonged prophylaxis (24.4%). Adherence to guidelines was higher in persons under 18 years of age (84.9% compared to 65.5%, p < 0.001). According to the type of health coverage (social welfare, private insurance, public coverage, or community coverage), adherence was 33.3%, 64.4%, 78.8%, and 83.3%, respectively; p < 0.001. According to population (maternal and child, pediatric, specific pathologies, and general pathologies), adherence was 97.9%, 97.2%, 89.4%, and 63.2%, respectively; p < 0.001. Adherence was highest in neurosurgery (91.1%), obstetrics (82.4%), and cardiovascular surgery (72.9%), and lowest in otorhinolaryngology (47.8%), ophthalmology (50%), and urology (55.9%) (p < 0.001). The adjusted analysis showed the highest adherence to guidelines in persons under 18 (odds ratio [OR]: 4.97; 95% confidence interval [CI 95]: 1.13-21.80); emergency surgery (OR: 2.18; CI 95: 1.11-4.26); and public, private, and community facilities (OR: 9.35; CI 95: 3.85-22.70). Adherence was also higher in facilities for maternal and child care and specific pathologies (OR: 10.52; CI 95, 1.30-85.12), cardiovascular surgery, neurosurgery, obstetrics (OR: 2.73; CI 95: 1.55-4.78), and facilities with programs to optimize the use of antimicrobial drugs (OR 1.95; CI 95, 1.10-3.45). CONCLUSIONS: Adherence to guidelines was 67%. Incorrect, unnecessary, and prolonged use of antibiotics were the most frequent forms of non-adherence. Adherence was higher with younger patients, where programs exist to optimize the use of antimicrobial drugs, where there is private or public health coverage, with the pediatric population, for specific pathologies, in emergency surgery, and in certain specialties.

OBJETIVO: Avaliar o nível de adesão às diretrizes (AD) de profilaxia cirúrgica em instituições de saúde da Argentina e os determinantes da não adesão (NA). MÉTODOS: Estudo multicêntrico transversal realizado em 35 centros na Argentina. Determinamos o nível de AD e as formas de NA, comparados segundo as características das seguintes variáveis: indicação antibiótica, anestesista, cirurgia, instituição e idade do paciente. Aplicamos um modelo de regressão logística ajustado. RESULTADOS: Revisamos um total de 1083 procedimentos cirúrgicos. A taxa de AD foi de 67%. As formas mais frequentes de NA foram: antibiótico incorreto (28,9%), profilaxia desnecessária (25,5%) e profilaxia prolongada (24,4%). A AD foi mais elevada em pacientes com menos de 18 anos (84,9% vs. 65,5%, p<0,001); também houve variações segundo o tipo de instituição (instituição de seguridade social, privada, pública ou comunitária, com adesão de 33,3%, 64,4%, 78,8% e 83,3%, respectivamente; p<0,001) e segundo a população (materno-infantil, pediátrica, com patologia específica ou geral, com adesão de 97,9%, 97,2%, 89,4% e 63,2%, respectivamente; p<0,001). A AD foi maior em neurocirurgia (91,1%), obstetrícia (82,4%) e cirurgia cardiovascular (72,9%) e menor em otorrinolaringologia (47,8%), oftalmologia (50%) e urologia (55,9%) (p<0,001). A análise ajustada mostrou uma AD mais elevada em pacientes com menos de 18 anos (odds ratio [OR]: 4,97, intervalo de confiança de 95% [IC95%]: 1,13-21,80), em cirurgias de emergência (OR: 2,18, IC95%: 1,11-4,26) e em instituições públicas, privadas ou comunitárias (OR: 9,35, IC95%: 3,85-22,70). A AD também foi superior em instituições para população materno-infantil ou para populações específicas (OR: 10,52; IC95%: 1,30-85,12), cirurgia cardiovascular, neurocirurgia, obstetrícia (OR: 2,73; IC95%: 1,55-4,78) e em instituições com programas para a otimização do uso de antimicrobianos (OR: 1,95; IC95%: 1,10-3,45). CONCLUSÕES: A AD foi de 67%; as formas mais frequentes de NA foram o uso incorreto, desnecessário e prolongado de antibióticos. A AD foi maior em pacientes mais jovens, em instituições com programas para a otimização do uso de antimicrobianos, em instituições privadas ou públicas e em populações pediátricas ou específicas, nos procedimentos cirúrgicos de emergência e em certas especialidades.

Estudio multicéntrico de adherencia a guías de profilaxis quirúrgica y sus determinantes en Argentina

[RESUMEN]. Objetivo. Evaluar el nivel de adherencia a las guías de profilaxis quirúrgica (AG) en instituciones de salud de Argentina y los determinantes de la falta de adherencia (NA). Métodos. Estudio multicéntrico de corte transversal en 35 centros de Argentina. Se determinaron el nivel de AG y las formas de NA y se comparó según características de la indicación antibiótica, anestesista, cirugía, institución y edad del paciente. Se ajustó un modelo de regresión logística. Resultados. Se revisaron 1 083 procedimientos quirúrgicos (PQ). La AG fue de 67%. Las formas más frecuentes de NA fueron: antibiótico incorrecto (28,9%), profilaxis innecesaria (25,5%) y profilaxis prolongada (24,4%). La AG fue mayor en menores de 18 años (84,9% frente a 65,5%, P < 0,001); según la dependencia (obra social, privada, pública o comunitaria) fue de 33,3%, 64,4%, 78,8% y 83,3%, respectivamente; P < 0,001) y según la población (maternoinfantil, pediátrica, con patología específica y general) fue de 97,9%, 97,2%, 89,4% y 63,2%, respectivamente; P < 0,001). La AG fue mayor en neurocirugía (91,1%), obstetricia (82,4%) y cirugía cardiovascular (CCV) (72,9%) y menor en otorrinolaringología (ORL) (47,8%), oftalmología (50%) y urología (55,9%) (P < 0,001). El análisis ajustado mostró mayor AG en menores de 18 años (odds ratio [OR]: 4,97; intervalo de confianza de 95% [IC95]: 1,13-21,80), cirugía de urgencia (OR: 2,18; IC95: 1,11-4,26) e institución pública, privada o de comunidad (OR: 9,35; IC95: 3,85-22,70). La AG también fue mayor en instituciones para población maternoinfantil o específica (OR: 10,52; IC95, 1,30-85,12), CCV, neurocirugía, obstetricia (OR: 2,73; IC95: 1,55-4,78) e instituciones con programas para la optimización del uso de antimicrobianos (PROA) (OR 1,95; IC95, 1,10-3,45). Conclusiones. LA AG fue de 67%; el uso incorrecto, innecesario y prolongado del antibiótico fueron las formas más frecuentes de NA. La AG fue mayor con menor edad, PROA, dependencia privada o pública y población pediátrica o específica, PQ de urgencia y ciertas especialidades.

[ABSTRACT]. Objective. Evaluate the level of adherence to guidelines on surgical prophylaxis in health facilities in Argentina and the determinants of non-adherence. Methods. Cross-sectional multicenter study in 35 centers in Argentina. The level of adherence to guidelines and the forms of non-adherence were determined and these were compared based on the characteristics of the indicated antibiotic, anesthesiologist, surgery, and facility, as well as patient age. An adjusted logistic regression model was used. Results. A total of 1,083 surgical procedures were reviewed. Adherence to guidelines was 67%. The most frequent forms of non-adherence were: incorrect antibiotic (28.9%), unnecessary prophylaxis (25.5%), and prolonged prophylaxis (24.4%). Adherence to guidelines was higher in persons under 18 years of age (84.9% compared to 65.5%, p < 0.001). According to the type of health coverage (social welfare, private insurance, public coverage, or community coverage), adherence was 33.3%, 64.4%, 78.8%, and 83.3%, respectively; p < 0.001. According to population (maternal and child, pediatric, specific pathologies, and general pathologies), adherence was 97.9%, 97.2%, 89.4%, and 63.2%, respectively; p < 0.001. Adherence was highest in neurosurgery (91.1%), obstetrics (82.4%), and cardiovascular surgery (72.9%), and lowest in otorhinolaryngology (47.8%), ophthalmology (50%), and urology (55.9%) (p < 0.001). The adjusted analysis showed the highest adherence to guidelines in persons under 18 (odds ratio [OR]: 4.97; 95% confidence interval [CI 95]: 1.13-21.80); emergency surgery (OR: 2.18; CI 95: 1.11-4.26); and public, private, and community facilities (OR: 9.35; CI 95: 3.85-22.70). Adherence was also higher in facilities for maternal and child care and specific pathologies (OR: 10.52; CI 95, 1.30-85.12), cardiovascular surgery, neurosurgery, obstetrics (OR: 2.73; CI 95: 1.55-4.78), and facilities with programs to optimize the use of antimicrobial drugs (OR 1.95; CI 95, 1.10-3.45). Conclusions. Adherence to guidelines was 67%. Incorrect, unnecessary, and prolonged use of antibiotics were the most frequent forms of non-adherence. Adherence was higher with younger patients, where programs exist to optimize the use of antimicrobial drugs, where there is private or public health coverage, with the pediatric population, for specific pathologies, in emergency surgery, and in certain specialties.

[RESUMO]. Objetivo. Avaliar o nível de adesão às diretrizes (AD) de profilaxia cirúrgica em instituições de saúde da Argentina e os determinantes da não adesão (NA). Métodos. Estudo multicêntrico transversal realizado em 35 centros na Argentina. Determinamos o nível de AD e as formas de NA, comparados segundo as características das seguintes variáveis: indicação antibiótica, anestesista, cirurgia, instituição e idade do paciente. Aplicamos um modelo de regressão logística ajustado. Resultados. Revisamos um total de 1083 procedimentos cirúrgicos. A taxa de AD foi de 67%. As formas mais frequentes de NA foram: antibiótico incorreto (28,9%), profilaxia desnecessária (25,5%) e profilaxia prolongada (24,4%). A AD foi mais elevada em pacientes com menos de 18 anos (84,9% vs. 65,5%, p<0,001); também houve variações segundo o tipo de instituição (instituição de seguridade social, privada, pública ou comunitária, com adesão de 33,3%, 64,4%, 78,8% e 83,3%, respectivamente; p<0,001) e segundo a população (materno-infantil, pediátrica, com patologia específica ou geral, com adesão de 97,9%, 97,2%, 89,4% e 63,2%, respectivamente; p<0,001). A AD foi maior em neurocirurgia (91,1%), obstetrícia (82,4%) e cirurgia cardiovascular (72,9%) e menor em otorrinolaringologia (47,8%), oftalmologia (50%) e urologia (55,9%) (p<0,001). A análise ajustada mostrou uma AD mais elevada em pacientes com menos de 18 anos (odds ratio [OR]: 4,97, intervalo de confiança de 95% [IC95%]: 1,13-21,80), em cirurgias de emergência (OR: 2,18, IC95%: 1,11-4,26) e em instituições públicas, privadas ou comunitárias (OR: 9,35, IC95%: 3,85-22,70). A AD também foi superior em instituições para população materno-infantil ou para populações específicas (OR: 10,52; IC95%: 1,30-85,12), cirurgia cardiovascular, neurocirurgia, obstetrícia (OR: 2,73; IC95%: 1,55-4,78) e em instituições com programas para a otimização do uso de antimicrobianos (OR: 1,95; IC95%: 1,10-3,45). Conclusões. A AD foi de 67%; as formas mais frequentes de NA foram o uso incorreto, desnecessário e prolongado de antibióticos. A AD foi maior em pacientes mais jovens, em instituições com programas para a otimização do uso de antimicrobianos, em instituições privadas ou públicas e em populações pediátricas ou específicas, nos procedimentos cirúrgicos de emergência e em certas especialidades.

Asociación entre Artritis Reumatoidea y otras enfermedades autoinmunes / Association between Rheumatoid Arthritis and other autoimmune diseases

Objetivos: Determinar la frecuencia de enfermedades autoinmunes (EAI) en pacientes con Artritis Reumatoidea (AR) y comparar la frecuencia de EAI entre pacientes con AR y sin AR ni otra EAI reumatológica. Material y Métodos: Estudio multicéntrico, observacional, analítico, retrospectivo. Se incluyeron pacientes consecutivos con AR (ACR/EULAR 2010) y como grupo control pacientes con diagnóstico inicial de Osteoartritis primaria (OA). Resultados: Se incluyeron 1549 pacientes: 831 con AR (84% mujeres, edad media 55.2 años [DE 13.6]) y 718 con OA (82% mujeres, edad media 67 años [DE 11.1]). La frecuencia de EAI en el grupo AR fue del 22% (n=183). Estos presentaron mayor frecuencia de EAI reumatológicas (9.4 vs 3.3%, p< 0.001), y menor frecuencia de EAI no reumatológicas que aquellos con OA (15.3 vs 20.5, p=0.007). La EAI reumatológica más prevalente fue el Síndrome de Sjögren, el cual fue más frecuente en el grupo AR (87.2 vs 29.2%, p< 0,001). La frecuencia de EAI reumatológicas en los pacientes con AR fue mayor en la forma erosiva (11 vs 6.8%, p=0.048). Conclusión: La frecuencia de EAI en los pacientes con AR fue del 22%, en quienes predominaron las de etiología reumatológica mientras que, las no reumatológicas predominaron en pacientes con OA.

Objectives: To determine the frequency of autoimmune diseases (AID) in Rheumatoid Arthritis (RA) patients and to compare this frequency between patients with and without RA or other rheumatologic AID. Methods: Multicenter, observational, analytical, retrospective study. Consecutive patients with diagnosis of RA (ACR/EULAR 2010) were included. Patients with initial diagnosis of primary ostearthritis (OA) were used as control group. Results: A total of 1549 patients were included: 831 RA (84% women, mean age 55.2 [±13.6]) and 718 OA (82% women, mean age 67 [± 11.1]). The frequency of AID in the RA group was 22% (n=183). RA patients showed higher frequency of rheumatologic AID (9.4 vs 3.3%, p< 0.001), and lower frequency of non-rheumatologic AID than OA patients (15.3 vs 20.5%, p= 0.007). The most prevalent rheumatic AID was Sjögren's Syndrome, which was more frequent in the AR group (87.2 vs 29.2%, p<0.001). The frequency of rheumatologic AID in RA patients was higher in those with erosive RA (11 vs 6.8%, p=0.048). Conclusion: The frequency of AID in RA patients was 22%. Rheumatologic AID were more frequent in RA patients, whereas non-rheumatologic AID prevailed in OA patients.

Evaluation of the Educational Needs in Argentine Patients with Rheumatoid Arthritis Using the SpENAT Questionnaire. / Evaluación de las necesidades educacionales de los pacientes con artritis reumatoide mediante el cuestionario SpENAT.

BACKGROUND: The SpENAT, a Spanish version of the Educational Needs Assessment Tool, is a self-completed questionnaire that assesses educational needs (ENs) with the purpose of providing tailored and patient-centered information. It consists of 39 questions grouped into the 7 following domains: Pain management, Movement, Feelings, Arthritic process, Treatments, Self-help measures and Support system. OBJECTIVES: The objective of the study was to describe the ENs of rheumatoid arthritis (RA) patients using the SpENAT and to determine the main sources of information consulted by these patients. MATERIAL AND METHODS: Multicenter, observational, cross-sectional study. We included consecutive patients≥18 years with diagnosis of RA (ACR 87/ACR-EULAR 2010). Sociodemographic data, disease characteristics and clinimetric properties were recorded. All patients completed the SpENAT and were asked about the sources employed to obtain information about their disease. STATISTICAL ANALYSIS: Population characteristics were described. ENs were determined as percentages of the highest possible score for each domain. Needs for each domain according to sex, years of education, disease duration, use of biologicals and functional capacity were analyzed by means of ANOVA, and bivariate comparisons were made with Student's t-test and the Bonferroni correction. Correlation between domains was determined with the Spearman correlation coefficient. We compared patients' age by source of information with Student's t-test. RESULTS: We included 496 patients from 20 centers across the country. More ENs were observed in the domains of Movement, Feelings and the Arthritic process. Patients with higher educational level (>7 years) reported more ENs in the Arthritic process and Self-help measure domains. A higher functional impairment (HAQ-A≥0.87) was associated with more ENs in every domain. Patients with high activity showed more ENs than those in remission in the domains of Pain management, Movement, Feelings, Treatments and Support system, as well as those with low activity in Self-help measures and Support system domains. All SpENAT domains showed positive correlations among each other (P<.0001), the most important being Pain management/Movement and Treatments/Arthritic process (r≥0.7). The source of information most frequently consulted was the rheumatologist (93.95%); those who made use of Internet were on average younger (P=.0004). CONCLUSION: RA patients were very interested about knowing more about their disease. High functional impairment was associated with more ENs. Patients with high disease activity had higher EN levels in almost every domain. The rheumatologist was the main source of information for the patient with RA.

Evaluación de la implementación de un Programa de Uso Optimizado de Antimicrobianos en la pandemia de COVID-19 / Evaluation of an antimicrobial stewardship program implementation during the global outbreak of coronavirus desease (COVID-19)

Introducción: No obstante la baja frecuencia de infecciones bacterianas asociadas al COVID-19, la prevalencia del uso de antibióticos empíricos es de 70 a 90%. El objetivo primario del estudio fue evaluar el impacto de la implementación de un programa de optimización de antimicrobianos dirigido a pacientes con COVID-19 (PROA-COVID).Material y métodos: Estudio antes y después, retrospectivo, descriptivo y analítico. Se evaluó prevalencia y adecuación del uso de antibióticos antes y después de implementación del PROA-COVID en pacientes internados. Se estimó consumo mensual de antibióticos en DDD/100 pacientes-día y costos por uso inadecuado.Resultados: Se incluyeron 153 pacientes, 75 antes y 78 después de la intervención, sin diferencias significativas en las características poblacionales entre ambos períodos. Las formas clínicas moderadas-severas fueron más frecuentes postintervención (p=0,03). La implementación mostró una disminución significativa en prevalencia de uso (64% vs 41%, p=0,004), con aumento de uso adecuado (37,5% vs. 46,8%, p=NS). La indicación innecesaria fue mayor antes del PROA (80% vs 50%, p=0,03) y la duración del tratamiento postintervención (13,3% vs. 43,7%%, p=0,02). La implementación redujo el consumo de betalactámicos + IBL y azitromicina.No se observaron diferencias significativas en mortalidad, frecuencia de pase a UCC ni uso de antibioticoterapia combinada con macrólidos entre ambos períodos ajustando por severidad. Conclusiones: La implementación del PROA-COVID fue una estrategia efectiva para reducir el uso de antibióticos y optimizar sus indicaciones, lo que destaca la importancia de su aplicación rápida y oportuna.

ntroduction: Despite the low frequency of Covid-19-associated bacterial infections, empirical antibacterial treatment is as high as 70 to 90%. The primary goal of this study was to determine the impact of the implementation of an antimicrobial stewardship program to target Covid-19 patients (ASP-COVID).Materials and methods: Retrospective, descriptive, and analytic pre and post intervention study. Prevalence and adequacy of antibacterial treatment in hospitalized patients prior and after ASP-COVID implementation were assessed. Monthly antibiotic consumption in DDD/100 patients-day and costs related with inadequate usage were estimated. Results: One hundred and fifty three patients, 75 prior and 78 after ASP-COVID implementation, were included. No significant difference in population characteristics between both periods was observed. Moderate and severe clinical presentations were more frequent after the intervention (p=0,03). ASP implementation showed a significant reduction of antimicrobial treatment (64% vs 41%, p=0,004), with an increment of adequate usage (37,5% vs 46,8%, p=NS). Unnecessary usage was higher prior to ASP (80% vs 50%, p =0,03) and length of treatment post intervention (13,3% vs 43,7%%, p=0,02). Program implementation decreased beta lactam antibiotics + IBL and azithromycin consumption. After adjusting for severity, no significant difference was found in mortality, incidence of ICU admission nor combined antibacterial therapy with macrolides between both periods.Conclusions: ASP-COVID implementation was an effective strategy in reducing antimicrobial usage and in optimizing antibacterial treatment indications, highlighting the importance of its rapid and timely application.

Detection of toxigenic Clostridioides --#1;Clostridium--#3; difficile: Usefulness of two commercially available enzyme immunoassays and a PCR assay on stool samples and stool isolates / Detección de Clostridioides --#1;Clostridium--#3; difficile toxigénico: utilidad de dos métodos de enzimoinmunoensayo comerciales y una PCR en las muestras de materia fecal y en los respectivos aislamientos

The best laboratory diagnostic approach to detect Clostridioides --#1;Clostridium--#3; difficile infection (CDI) is a subject of ongoing debate. With the aim of evaluating four laboratory diagnostic methods, 250 unformed stools from patients with suspected CDI submitted to nine medical center laboratories from November 2010 to December 2011, were studied using: (1) an immunochromatographic rapid assay test that combines the qualitative determination of glutamate dehydrogenase (GDH) plus toxins A and B (QAB), the CDIFF QUIK CHEK COMPLETE assay; (2) an enzyme immunoassay for qualitative determination of toxins A and B, the RIDASCREENTC. difficile Toxin A/B assay (RAB); (3) a PCR for the toxin B gene assay (PCR); and (4) the toxigenic culture (TC).C. difficile isolates from direct toxin negative stools by QAB, RAB and PCR were evaluated for toxigenicity by the same direct tests, in order to assess the contribution of the TC (QAB-TC, RAB-TC, PCR-TC). A combination of the cell culture cytotoxicity neutralization assay (CCCNA) in stools, and the same assay on isolates from direct negative samples (CCCNA-TC) was considered the reference method (CCCNA/CCCNA-TC). Of the 250 stools tested, 107 (42.8%) were positive by CCCNA/CCCNA-TC. The GDH and PCR/PCR-TC assays were the most sensitive, 91.59% and 87.62%, respectively. The QAB, RAB, QAB/QAB-TC and RAB/RAB-TC had the highest specificities, ca. 95%. A negative GDH result would rule out CDI, however, its low positive likelihood ratio (PLR) of 3.97 indicates that a positive result should always be complemented with the detection of toxins. If the RAB, QAB, and PCR assays do not detect toxins from direct feces, the toxigenic culture should be performed. In view of our results, the most accurate and reliable methods to be applied in a clinical microbiology laboratory were the QAB/QAB-TC, and RAB/RAB-TC, with PLRs >10 and negative likelihood ratios <0.30.

El mejor procedimiento para realizar el diagnóstico de laboratorio de la infección causada por Clostridioides --#1;Clostridium--#3; difficile (ICD) es aún objeto de debate. Con el fin de evaluar cuatro métodos diagnósticos de laboratorio, se estudiaron 250 muestras de heces diarreicas provenientes de pacientes con sospecha de ICD remitidas a los laboratorios de nueve centros médicos entre noviembre de 2010 y diciembre de 2011. Dichas muestras se analizaron mediante los siguientes métodos:1) un ensayo rápido inmunocromatográfico que combina la detección cualitativa de la glutamato deshidrogenasa (GDH) y de las toxinas Ay B (QAB), CDIFF QUIK CHEK COMPLETE;2) un enzimoinmunoanálisis para la determinación cualitativa de las toxinas A/B, RIDASCREENTC. difficile Toxin A/B (RAB);3) un método molecular basado en PCR para la detección del gen que codifica la toxina B (PCR) y 4) el cultivo toxigénico (TC). Como método de referencia se utilizó la combinación del ensayo de citotoxicidad sobre cultivo de células con la neutralización de toxina mediante anticuerpo específico en los filtrados de las heces (CCCNA) y el mismo método en sobrenadantes de aislamientos de C. difficile (CCCNA-TC). La toxigenicidad de las cepas aisladas de muestras directas negativas con QAB, RAB y PCR se evaluó con los mismos métodos, con el propósito de detectar la contribución del TC (QAB-TC, RAB-TC, PCR-TC). De las 250 muestras estudiadas, 107 (42,8%) fueron positivas por CCCNA/CCCNA-TC. Los métodos GDH y PCR/PCR-TC fueron los más sensibles: 91,59 y 87,62%, respectivamente. Los métodos QAB, RAB, QAB/QAB-TC y RAB/RAB-TC mostraron las mayores especificidades, del 95%, aproximadamente. Un resultado negativo para GDH excluiría la ICD, pero su baja razón de verosimilitud positiva (PLR), que fue 3,97, indica que un resultado positivo debe complementarse con la detección de toxinas. Cuando no se detectan toxinas directas por RAB, QAB ni PCR, debería realizarse el TC. De acuerdo con nuestros resultados, los métodos más precisos y confiables para ser aplicados en un laboratorio de microbiología clínica son QAB/QAB-TC y RAB/RAB-TC, con una PLR> 10 y una razón de verosimilitud negativa < 0,30.

Detection of toxigenic Clostridioides [Clostridium] difficile: Usefulness of two commercially available enzyme immunoassays and a PCR assay on stool samples and stool isolates.

The best laboratory diagnostic approach to detect Clostridioides [Clostridium] difficile infection (CDI) is a subject of ongoing debate. With the aim of evaluating four laboratory diagnostic methods, 250 unformed stools from patients with suspected CDI submitted to nine medical center laboratories from November 2010 to December 2011, were studied using: (1) an immunochromatographic rapid assay test that combines the qualitative determination of glutamate dehydrogenase (GDH) plus toxins A and B (QAB), the CDIFF QUIK CHEK COMPLETE assay; (2) an enzyme immunoassay for qualitative determination of toxins A and B, the RIDASCREEN™ C. difficile Toxin A/B assay (RAB); (3) a PCR for the toxin B gene assay (PCR); and (4) the toxigenic culture (TC). C. difficile isolates from direct toxin negative stools by QAB, RAB and PCR were evaluated for toxigenicity by the same direct tests, in order to assess the contribution of the TC (QAB-TC, RAB-TC, PCR-TC). A combination of the cell culture cytotoxicity neutralization assay (CCCNA) in stools, and the same assay on isolates from direct negative samples (CCCNA-TC) was considered the reference method (CCCNA/CCCNA-TC). Of the 250 stools tested, 107 (42.8%) were positive by CCCNA/CCCNA-TC. The GDH and PCR/PCR-TC assays were the most sensitive, 91.59% and 87.62%, respectively. The QAB, RAB, QAB/QAB-TC and RAB/RAB-TC had the highest specificities, ca. 95%. A negative GDH result would rule out CDI, however, its low positive likelihood ratio (PLR) of 3.97 indicates that a positive result should always be complemented with the detection of toxins. If the RAB, QAB, and PCR assays do not detect toxins from direct feces, the toxigenic culture should be performed. In view of our results, the most accurate and reliable methods to be applied in a clinical microbiology laboratory were the QAB/QAB-TC, and RAB/RAB-TC, with PLRs >10 and negative likelihood ratios <0.30.