Long-Term Carbapenems Antimicrobial Stewardship Program.

OBJECTIVE: To evaluate clinical and antibiotic resistance impact of carbapenems stewardship programs. METHODS: descriptive study, pre-post-intervention, between January 2012 and December 2019; 350-bed teaching hospital. Prospective audit and feedback to prescribers was carried out between January 2015 and December 2019. We evaluate adequacy of carbapenems prescription to local guidelines and compare results between cases with accepted or rejected intervention. Analysis of antibiotic-consumption and hospital-acquired multidrug-resistant (MDR) bloodstream infections (BSIs) was performed. RESULTS: 1432 patients were followed. Adequacy of carbapenems prescription improved from 49.7% in 2015 to 80.9% in 2019 (p < 0.001). Interventions on prescription were performed in 448 (31.3%) patients without carbapenem-justified treatment, in 371 intervention was accepted, in 77 it was not. Intervention acceptance was associated with shorter duration of all antibiotic treatment and inpatient days (p < 0.05), without differences in outcome. During the period 2015-2019, compared with 2012-2014, decreased meropenem consumption (Rate Ratio 0.58; 95%CI: 0.55-0.63), candidemia and hospital-acquired MDR BSIs rate (RR 0.62; 95%CI: 0.41-0.92, p = 0.02), and increased cefepime (RR 2; 95%CI: 1.77-2.26) and piperacillin-tazobactam consumption (RR 1.17; 95%CI: 1.11-1.24), p < 0.001. CONCLUSIONS: the decrease and better use of carbapenems achieved could have clinical and ecological impact over five years, reduce inpatient days, hospital-acquired MDR BSIs, and candidemia, despite the increase in other antibiotic-consumption.

Epidemiology and impact of a multifaceted approach in controlling central venous catheter associated blood stream infections outside the intensive care unit.

BACKGROUND: Outside ICUs, CVC-ABSIs epidemiology and the results of strategies for their prevention are not well known. The aim of this study was to investigate the epidemiology and the impact of a multifaceted "bundle" approach in controlling CVC-ABSIs outside ICU. METHODS: From 1991 we performed prevalence studies of device and parenteral nutrition use, and prospective surveillance of all episodes of CVC-ABSIs in a 350-bed teaching hospital. CVC-ABSIs incidence/1,000 inpatient-days was calculated. An estimated CVC-ABSIs incidence/1,000 catheter-days was calculated based on the prevalence rates of catheter use and the total number of inpatient-days in each year. On november 2008, an education programme was instituted for care of catheter lines: reinforcing instructions in aseptic insertion technique, after care and hand-washing; in order to assess the adherence to these measures the quantity of alcohol-based hand-rub consumption/1,000 patient-days was quoted in litres. From January 2009, a checklist intervention for CVC insertion in ICU was started: hand hygiene, using full barrier precautions, cleaning the skin with alcoholic chlorhexidine, avoiding femoral access and removing unnecessary catheters. Compliance with the central line insertion checklist was measured by real-time audits and was achieved in 80% of cases. RESULTS: Prevalence of use of CVC and parenteral nutrition was similar throughout the study. We followed-up 309 CVC-ABSIs cases. Estimated CVC-ABSIs rate progressively increased to 15.1/1,000 catheter-days in 2008 (0.36/1,000 inpatient-days). After the intervention, the alcohol-based hand-rub consumption increased slightly and estimated CVC-ABSIs rate fell to 10.1 /1,000 catheter-days in last three years (0.19/1,000 inpatient-days), showing a 32.9% decrease. The infection rates achieved were lower in Internal Medicine wards: decreased from 14.1/1,000 catheter-days (0.17/patient-days) in 2008 to 5.2/1,000 catheter-days (0.05/1,000 inpatient-days) in last three years, showing a 63.1% decrease. In 2009, the estimated CVC-ABSIs incidence rate was significantly lower in the Internal Medicine ward compared to the Surgery ward: rate ratio (RR) = 0.14, 95%CI: 0.03-0.60), and within the Internal Medicine ward, the estimated CVC-ABSIs incidence rate was significantly lower in 2009 compared to 2008 (RR = 0.20, 95%CI: 0.04-0.91). CONCLUSION: The rate of CVC-ABSIs increased outside-ICU, and the implementation of multifaceted infection control programme decreased their clinical impact.

ANCA-positive vasculitis induced by levamisole-adulterated cocaine and nephrotic syndrome: The kidney as an unusual target.

PATIENT: Male, 36 FINAL DIAGNOSIS: Levamisole-induced vasculopathy Symptoms: Purpuric skin lesions Medication: Levamisole Clinical Procedure: - Specialty: Internal Medicine. OBJECTIVE: Unusual clinical course. BACKGROUND: Levamisole has been detected in seized cocaine samples and a levamisole-induced vasculopathy (LIV) has been described, mainly focused on skin. CASE REPORT: A 36-year-old Caucasian man with history of antibodies to hepatitis C infection (negative hepatitis C virus RNA and negative HIV serology), smoking, and intravenous use of cocaine and brown heroin, presented to the hospital with purpuric skin lesions on extremities and earlobes. One month before the current presentation, a skin punch biopsy of one of these lesions was performed, showing histopathologic findings suggestive of mixed cryoglobulinemia. Laboratory testing revealed leukopenia, renal failure, and nephrotic syndrome. Antimyeloperoxidase antineutrophil cytoplasmic antibodies (MPO-ANCA) were positive. The previous skin punch biopsy was revised and demonstrated pathologic findings consistent with leukocytoclastic vasculitis. An analysis of a cocaine sample for personal use, provided by the patient, was performed using mass spectrometry-gas chromatography and levamisole was detected. Three boluses of intravenous methylprednisolone were administered, followed by oral prednisone 1 mg/Kg per day. Skin lesions and renal function improved. CONCLUSIONS: To our knowledge, this is the first report of nephrotic syndrome induced by levamisole-adulterated cocaine, proven by cocaine sample toxicology. Lack of renal biopsy is a limitation of this report.

Extrapulmonary tuberculosis: epidemiology and risk factors

Objetivo: Conocer la epidemiología y los factores de riesgo asociados con la tuberculosis extrapulmonar(EPTB).Método: Los casos de tuberculosis (TB) diagnosticadas entre 1991-2008 en una población caucásica fueron clasificados como EPTB o TB pulmonar (PTB). De todos los casos, 63,7% fueron seguidos en una consulta monográfica de TB. Se utilizó un protocolo estandarizado para la recogida de los datos, incluyendo: sexo, edad, vacunación con BCG, contacto con algún paciente con PTB, tabaquismo, alcoholismo, diabetes mellitus, corticoides/fármacos inmunosupresores e infección por el VIH. Se compararon las variables entre los grupos de EPTB y de PTB. El análisis estadístico se basó en un estudio de regresión logística. Se calcularon los odds ratio (OR) y sus intervalos de confianza (IC) del 95%.Resultados: Entre 2.161 casos diagnosticados, 1.186 fueron PTB y 705 EPTB. La incidencia global de TB disminuyó desde 79.9/100.000 en 1992 hasta 27.1/100.000 en 2008, p<0,05. El número de casos de EPTB disminuyó de forma más lenta que el de PTB. La proporción de EPTB aumentó desde 30,6% de los casos en 1991-1996 hasta 37,6% en 2003-2008 (la localización ganglionar aumentó un 27%), p<0,05 en un ji al cuadrado de tendencia. En el estudio multivariante, ser mujer (OR 2,04; IC 95%: 1,56-2,66) y la edad (OR1,02; IC 95%: 1,01-1,022) se asociaron con EPTB mientras que el alcoholismo (OR 0,33; IC 95%: 0,20-0,52),

Objective To describe the epidemiology and risk factors associated with extra-pulmonary tuberculosis (EPTB).Method Cases of tuberculosis (TB) diagnosed from 1991 to 2008 in a Caucasian population were classified as EPTB or pulmonary TB (PTB). Of all cases, 63.7% were followed up in a specialist TB unit. A standardised protocol for data collection was used, including: gender, age, BCG vaccination, contact with PTB patient, smoking habit, alcohol abuse, diabetes mellitus, immunosuppressive drugs/steroids and HIV-status. These variables were compared between EPTB and PTB groups. Statistical analysis was based on logistic regression. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated. Results Among the 2,161 cases diagnosed, 1,186 were PTB and 705 EPTB. The overall TB incidence had fallen from 79.9/100,000 in 1992 to 27.1/100,000 in 2008, P<.05. The number of EPTB cases decreased more slowly than PTB. EPTB increased from 30.6% of cases in 1991-1996 to 37.6% in 2003-2008 (lymphatic site increased 27%), by trend test P<.05. At multivariate level, being female (OR 2.04; 95% CI: 1.56-2.66) and age (OR 1.02; 95% CI: 1.01-1.022) were associated with EPTB, while alcohol abuse (OR 0.33; 95% CI: 0.20-0.52), smoking habit (OR 0.45; 95%CI: 0.34-0.59), contact with PTB patients (OR 0.57; 95% CI: 0.44-0.76) and BCG vaccination (OR 0.64; 95% CI: 0.44-0.92) had a protective effect. The proportion of female gender and age of patients increased over time, whilst there was a decrease in BCG vaccinated patients. Conclusions Whilst there has been a reduction in the overall incidence of TB, the proportion of EPTB increased. The proportional increase in EPTB could be explained by an increase in life expectancy and the predominance of women in the population, and by a decline in BCG vaccinated patients(AU) el tabaquismo (OR 0,45; IC 95%: (..) (AU)

Non-cirrhotic portal hypertension in human immunodeficiency virus-infected patients: a new challenge in antiretroviral therapy era.

Non-cirrhotic portal hypertension (NCPH) has been recently reported as a liver disease in Human Immunodeficiency Virus (HIV)-infected patients under antiretroviral therapy (ART). Combination of non-exclusive mechanisms has been described: primary endothelial damage of terminal portal veins induced by HIV or immunologic disorders, mitochondrial toxicity by didanosine and prothrombotic state. It is characterized by heterogeneous liver histological findings, frequently identified as nodular regenerative hyperplasia and clinical manifestations of portal hypertension with well-preserved liver function. We describe herein two HIV-infected patients with clinical picture suggestive of NCPH. Besides the case reports, we briefly address questions to apply to patient care in clinical practice.

Extrapulmonary tuberculosis: epidemiology and risk factors.

OBJECTIVE: To describe the epidemiology and risk factors associated with extra-pulmonary tuberculosis (EPTB). METHOD: Cases of tuberculosis (TB) diagnosed from 1991 to 2008 in a Caucasian population were classified as EPTB or pulmonary TB (PTB). Of all cases, 63.7% were followed up in a specialist TB unit. A standardised protocol for data collection was used, including: gender, age, BCG vaccination, contact with PTB patient, smoking habit, alcohol abuse, diabetes mellitus, immunosuppressive drugs/steroids and HIV-status. These variables were compared between EPTB and PTB groups. Statistical analysis was based on logistic regression. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated. RESULTS: Among the 2,161 cases diagnosed, 1,186 were PTB and 705 EPTB. The overall TB incidence had fallen from 79.9/100,000 in 1992 to 27.1/100,000 in 2008, P<.05. The number of EPTB cases decreased more slowly than PTB. EPTB increased from 30.6% of cases in 1991-1996 to 37.6% in 2003-2008 (lymphatic site increased 27%), by trend test P<.05. At multivariate level, being female (OR 2.04; 95% CI: 1.56-2.66) and age (OR 1.02; 95% CI: 1.01-1.022) were associated with EPTB, while alcohol abuse (OR 0.33; 95% CI: 0.20-0.52), smoking habit (OR 0.45; 95%CI: 0.34-0.59), contact with PTB patients (OR 0.57; 95% CI: 0.44-0.76) and BCG vaccination (OR 0.64; 95% CI: 0.44-0.92) had a protective effect. The proportion of female gender and age of patients increased over time, whilst there was a decrease in BCG vaccinated patients. CONCLUSIONS: Whilst there has been a reduction in the overall incidence of TB, the proportion of EPTB increased. The proportional increase in EPTB could be explained by an increase in life expectancy and the predominance of women in the population, and by a decline in BCG vaccinated patients.

Non-hospital-associated methicillin-resistant Staphylococcus aureus and MRSA chronic carrier patients in infection control.

This study reports research on methicillin-resistant Staphylococcus aureus (MRSA) colonized-infected patients who were admitted to a 320-bed hospital. Specifically, we report on the difficulties related to MRSA infection control as a consequence of the increasing incidence of non-hospital-associated MRSA acquisition and patients as chronic carriers who are frequently readmitted to the hospital.

[Cutaneous tuberculosis: a 15-year descriptive study]. / Tuberculosis cutánea: estudio descriptivo de 15 años.

INTRODUCTION: Cutaneous tuberculosis has experienced a resurgence following a period of decline. The aim of this study was to determine the clinical and epidemiological characteristics of cutaneous tuberculosis in the Ferrol Healthcare Area (Spain). METHODS: Between 1991-2005, 1139 new cases of tuberculosis were diagnosed in Ferrol and submitted to a descriptive analysis. Cutaneous involvement was investigated in all cases. RESULTS: Among 1139 patients, 55 cases of cutaneous tuberculosis were diagnosed (4.8%). The condition was more frequent in women (70.9%), average age was 44.1 +/- 23.3 years, and 56.4% of patients were treated with 6HR2Z-E. Among the 55 cases, 26 (2.3%) were true cutaneous tuberculosis and 29 (2.5%) were tuberculids. In the 26 cases of true tuberculosis, the most frequent form was scrofuloderma (32.7%), followed of lupus vulgaris (7.2%), tuberculous gumma (3.6%), and tuberculosis verrucosa cutis (3.6%). The most frequent locations were the neck, face and trunk, and in 76.9% other sites were involved (lymph nodes 14, bone 6, lung 4, and intestine 1). In the 29 cases with tuberculids, erythema nodosum was the most frequent form (49.1%) followed by erythema induratum of Bazin (3.6%). The lower extremities were affected in all cases and there was simultaneous involvement of other site in 51.9%. In patients with true cutaneous tuberculosis, the diagnostic yield was greater (necrotizing granulomas in 70.6% of biopsies and positive Löwenstein culture for Mycobacterium tuberculosis in 77.8%) and average age was higher than in patients with tuberculids (P < .05). CONCLUSION: Cutaneous tuberculosis is uncommon, preferentially affects women, and is usually associated with tuberculous disease in other locations, particularly in the case of scrofuloderma.

Tuberculosis cutánea: estudio descriptivo de 15 años / Cutaneous tuberculosis: a 15-year descriptive study

Introducción. La tuberculosis cutánea ha resurgido después de un tiempo en descenso. El objetivo del estudio es conocer las características clínicas y epidemiológicas de la tuberculosis cutánea en el área sanitaria de Ferrol. Métodos. Se analizaron de forma descriptiva 1.139 casos nuevos de tuberculosis diagnosticados en Ferrol entre 1991 y 2005, se buscó en todos los pacientes si existía afectación cutánea. Resultados. De los 1.139 pacientes, se diagnosticaron 55 casos de tuberculosis cutánea (4,8%). Fue más frecuente en mujeres (70,9%) y la media de edad fue de 44,1 6 23,3 años. El 56,4% fueron tratados con pauta de 6HR2Z-E. De los 55 casos, 26 (2,3%) fueron tuberculosis cutánea verdadera y 29 (2,5%) tubercúlides. En los 26 casos de tuberculosis verdadera, el escrofuloderma fue la forma más frecuente (32,7%), seguida de lupus vulgar (7,2%), goma tuberculoso (3,6%) y tuberculosis verrucosa (3,6%). La localización más frecuente fue en el cuello, la cara y el tronco, y se diagnosticó afectación simultánea de la tuberculosis en otras localizaciones en el 76,9% (ganglionar 14 casos, ósea 6, pulmonar 4 e intestinal 1). En los 29 casos con tubercúlides, el eritema nudoso fue la forma más frecuente (49,1%) seguido del eritema indurado de Bazin (3,6%). Se localizaron siempre en miembros inferiores y existió otra afectación simultánea de tuberculosis en el 51,9% de los casos. En los pacientes con tuberculosis verdaderas se dio una mayor rentabilidad diagnóstica (granulomas necrosantes en el 70,6% de las biopsias y cultivo Löwenstein positivo para Mycobacterium tuberculosis en el 77,8%) y una media de edad más alta que en los pacientes con tubercúlides, p < 0,05. Conclusión. La tuberculosis cutánea es poco frecuente, afecta con preferencia a las mujeres y suele asociarse a otras localizaciones de la enfermedad, sobre todo el escrofuloderma (AU)

Introduction. Cutaneous tuberculosis has experienced a resurgence following a period of decline. The aim of this study was to determine the clinical and epidemiological characteristics of cutaneous tuberculosis in the Ferrol Healthcare Area (Spain). Methods. Between 1991-2005, 1139 new cases of tuberculosis were diagnosed in Ferrol and submitted to a descriptive analysis. Cutaneous involvement was investigated in all cases. Results. Among 1139 patients, 55 cases of cutaneous tuberculosis were diagnosed (4.8%). The condition was more frequent in women (70.9%), average age was 44.1 6 23.3 years, and 56.4% of patients were treated with 6HR2Z-E. Among the 55 cases, 26 (2.3%) were true cutaneous tuberculosis and 29 (2.5%) were tuberculids. In the 26 cases of true tuberculosis, the most frequent form was scrofuloderma (32.7%), followed of lupus vulgaris (7.2%), tuberculous gumma (3.6%), and tuberculosis verrucosa cutis (3.6%). The most frequent locations were the neck, face and trunk, and in 76.9% other sites were involved (lymph nodes 14, bone 6, lung 4, and intestine 1). In the 29 cases with tuberculids, erythema nodosum was the most frequent form (49.1%) followed by erythema induratum of Bazin (3.6%). The lower extremities were affected in all cases and there was simultaneous involvement of other site in 51.9%. In patients with true cutaneous tuberculosis, the diagnostic yield was greater (necrotizing granulomas in 70.6% of biopsies and positive Löwenstein culture for Mycobacterium tuberculosis in 77.8%) and average age was higher than in patients with tuberculids (P <.05). Conclusion. Cutaneous tuberculosis is uncommon, preferentially affects women, and is usually associated with tuberculous disease in other locations, particularly in the case of scrofuloderma (AU)