Effectiveness and safety of ertapenem used in hospital-at-home units: data from Spanish Outpatient Parenteral Antimicrobial Therapy Registry.

AIM: To evaluate the effectiveness and safety of ertapenem in patients hospitalized at home. PATIENTS & METHODS: Retrospective analysis of data from Spanish Outpatient Parenteral Antimicrobial Therapy (OPAT) registry. RESULTS: Data from 1428 patients (median age 70 years; 5.4% institutionalized) and 1547 infectious processes (24% self-administration) were analyzed. Clinical cure or improvement was achieved in 93.8% of cases. Rate of related readmissions was 4.2%, of clinically important complications -3.9%, and of adverse drug reactions -3.2%. High comorbidity burden, contagion in nursing home and certain types of infection were associated with worse prognosis. Self-administration was effective and safe, except in case of nursing home-acquired infections. CONCLUSION: Ertapenem OPAT was effective and safe. Caregivers in nursing homes should be better trained in OPAT-related procedures.

Daptomycin for outpatient parenteral antibiotic therapy: a European registry experience.

A retrospective analysis of data from patients receiving daptomycin as outpatient parenteral antimicrobial therapy (OPAT) within the European Cubicin Outcomes Registry and Experience (EU-CORE(SM)) was performed. Of 4592 enrolled patients in 15 countries, 550 (12%) received daptomycin OPAT. Of these, 149 (27%) received daptomycin without hospital admission, 84% had significant underlying diseases and 44% were ≥65 years of age. Most frequently treated infections were complicated skin and soft-tissue infections (28%), osteomyelitis (17%), foreign body/prosthetic infections (15%) and endocarditis (14%). In patients with culture results available, Staphylococcus aureus and coagulase-negative staphylococci were the most commonly isolated primary pathogens [n = 218 (46%) and n = 102 (21%), respectively]. Daptomycin was typically used at doses of 6 mg/kg (n = 210; 38%) and 4 mg/kg (n = 160; 29%), with concomitant antibiotics used in 41%. The median treatment duration was 22 days (range 1-300 days), with a median of 13 OPAT days (range 1-290 days). Overall clinical success was observed in 89%, with high success rates across the wide range of infections, including those caused by meticillin-resistant and meticillin-susceptible S. aureus (88% and 90%, respectively). Daptomycin exhibited a favourable safety profile; 3.1% of patients discontinued treatment owing to an adverse event. These data demonstrate that daptomycin is effective and well tolerated in the treatment of a wide range of Gram-positive infections in the outpatient setting. Ease of administration of daptomycin, via a daily 2-min injection, and its efficacy and safety combine to make it an attractive treatment option for OPAT.

Implementation of a bundle of actions to improve adherence to the Surviving Sepsis Campaign guidelines at the ED.

PURPOSES: We had previously demonstrated surviving sepsis campaign guidelines had not had enough impact at our Emergency Department. BASIC PROCEDURES: Actions directed to increase the qualification of our staff and residents, to facilitate guidelines divulgation and to improve spatial conditions by creating a High Dependency Unit were implemented as a bundle. The impact of these actions on the achievement of early objectives of the campaign and on mortality was analyzed. MAIN FINDINGS: Following campaign guidelines was more frequent after the implementation of these actions, as shown by less restrictive fluids administration for more severe cases (P = .001), earlier administration of antibiotics (P = .001) and lactate determination rate (46% vs. 12%). In-hospital mortality difference did not reach statistical difference. Physicians were able to identify high-risk patients on clinical grounds. PRINCIPAL CONCLUSIONS: The bundle of actions has had a moderate beneficial effect on our Emergency Department. High Dependency Units are useful for managing patients not fulfilling criteria for Intensive Care Unit admission.

Failure to implement evidence-based clinical guidelines for sepsis at the ED.

OBJECTIVE: The main objective was to evaluate if consensus "bundle" measures to optimize the treatment of sepsis have been integrated in our routine practice. We also tried to identify variables significantly associated to mortality. METHODS: An observational, unblinded study of those patients who, according to their physicians, met criteria for sepsis under its different stages of severity was conducted. Six items as proposed by surviving sepsis campaign were evaluated: (1) measurement of blood lactate; (2) obtaining blood samples for culture before use of antibiotics; (3) early use of antibiotics (>3 h); (4) fluid replacement with at least 20 mL/kg of crystalloids in the first hour, unless contraindicated, if hypotension or blood lactate >4 mmol/L; (5) use of vasoactive drugs, other than dopaminergic doses of dopamine, if hypotension or shock; (6) measurement of central venous pressure and central venous O2 saturation in shock. Data concerning several aspects of diagnosis, treatment, and consultation to ICU were collected. RESULTS: Compliance with published guidelines is poor after evaluating the 6 items proposed: 12.5% of shocked patients had determinations of blood lactate; 15% of septic patients had no blood cultures drawn; 32% had received their first dose of antibiotics in the first 3 hours after admission; 46.6% of the cases of severe sepsis or shock received a fluid aggressive therapy; 43.3% of the patients with an indication for vasoactive drugs received them; no patient had central venous pressure monitoring at the ED. In addition, intensive care specialists were seldom consulted (17%). Having used dopaminergic doses of dopamine and having a respiratory focus as a source of infection were independently associated to mortality, respective OR: 21 ([1.7-254.9]; 95% CI) and 9.6 ([1.7-52]; 95% CI). CONCLUSIONS: The "bundle" measures proposed in the surviving sepsis campaign seem not to have had enough impact in our ED. This is the start point of a "plan-do-study-act" process directed to improve the outcome of patients with sepsis at our institution.

Veinticinco años de hospitalización a domicilio en España / Twenty five years of hospital at home in Spain

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Outcome of Listeria monocytogenes prosthetic valve endocarditis: as bad as it looks?

In 1998 we presented 1 successfully treated case of Listeria monocytogenes prosthetic valve endocarditis and made a review of all the cases that had been published to date. We carry out an up-to-date review through Pub-Med of every case of Listeria monocytogenes prosthetic valve endocarditis; mortality rate is calculated and data from several clinical and therapeutical variables are collected; Fisher's exact test is used to identify those variables significantly associated with mortality. Four out of 23 patients died in hospital (17%); among all the variables included, only peripheral embolism (p=0.024), onset on a mechanical prosthesis (p=0.035) and having used only 1 antibiotic instead of a combination of drugs (p=0.026) were independently associated with mortality. Although the overall number of cases is too low to draw definite conclusions (n=23), mortality rate is lower than previously believed. Some variables that have traditionally been associated with a poor prognosis for endocarditides are not for the case of Listeria monocytogenes on valvular prostheses. It seems prudent to treat affected patients with a combination of ampicillin -- or vancomycin, if there is a history of beta-lactam allergy and ampicillin desensitization is not possible -- plus an aminoglycoside.