Infection control in long term care institutions for the elderly: A reflection document on the situation in Spain.

A progressively increasing percentage of the elderly live during the last years of their lives in nursing homes. Although these institutions are intended to mimic life at home as much as possible, they have characteristics that make them quite similar to a "nosocomiun", i.e. an establishment for the treatment of the sick. The very coexistence among the elderly, the fact of sharing caregivers and the very significant exposure to third parties, together with the frequent predisposing diseases to infection in this population, make infection frequent among residents and also easily transmissible. This leads us to ask what can be done to prevent infection in this environment and more specifically what is the state of the art of the matter in a Western European nation such as ours. The Board of Trustees of the Health Sciences Foundation has asked itself a series of questions on the subject of infection prevention in Nursing Homes, the structure of procedures, the legislation available, compliance with the measures indicated, the best indicators of the processes and therefore, the need to promote in Spain a document of recommendations to avoid infections in this poplation whose morbidity and mortality need not be highlighted. To this end, a multidisciplinary group of experts in different aspects of this problem has been convened and asked the proposed questions. The questions were discussed by the group as a whole and led to a series of conclusions agreed upon by the participants. The results of the meeting are reported below.

Empiric treatment in hospitalized community-acquired pneumonia. Impact on mortality, length of stay and re-admission.

OBJECTIVE: To evaluate adherence to guidelines when choosing an empirical treatment and its impact upon the prognosis of community-acquired pneumonia (CAP). METHODS: A prospective multicentre study was conducted in 425 CAP patients hospitalized on ward. Initial empirical treatment was classified as adhering or not to Spanish guidelines. Adherent treatment was defined as an initial antimicrobial regimen consisting of beta-lactams plus macrolides, beta-lactam monotherapy and quinolones. Non-adherent treatments included macrolide monotherapy and other regimens. Initial severity was graded according to pneumonia severity index (PSI). The end point variables were mortality, length of stay (LOS) and re-admission at 30 days. RESULTS: Overall 30-day mortality was 8.2%, the mean LOS was 8+/-5 days, and the global re-admission rate was 7.6%. Adherence to guidelines was 76.5%, and in most cases the empirical treatment consisted of beta-lactam and macrolide in combination (57.4%). Logistic regression analysis showed that other regimens were associated with higher mortality OR=3 (1.2-7.3), after adjusting for PSI and admitting hospital. Beta-lactam monotherapy was an independent risk factor for re-admission. LOS was independently associated with admitting hospital and not with antibiotics. CONCLUSIONS: A high adherence to CAP treatment guidelines was found, though with considerable variability in the empirical antibiotic treatment among hospitals. Non-adherent other regimens were associated with greater mortality. Beta-lactam monotherapy was associated with an increased re-admission rate.

[Can home prophylaxis for venous thromboembolism reduce mortality rates in patients with chronic obstructive pulmonary disease?]. / Puede reducir la mortalidad de los pacientes con EPOC la profilaxis domiciliaria de la enfermedad tromboembólica venosa?

OBJECTIVE: The incidence of venous thromboembolism (VTE) in patients with chronic obstructive pulmonary disease (COPD) ranges from 20% to 60% in different studies and the mortality rates are higher for patients with both conditions. Heparin prophylaxis is therefore usually prescribed for COPD patients who are hospitalized for exacerbation. Once their situation becomes stable, however, they are discharged to home without prophylaxis even though the low level of physical activity their disease allows continues to put them at risk for VTE. The aim of this study was to test the efficacy of home heparin prophylaxis on reducing the incidence of VTE and on the overall mortality rate in patients with severe COPD. PATIENTS AND METHODS: We conducted a prospective, randomized controlled trial of 87 patients with severe COPD who required home oxygen therapy (> or =18 h/d) and whose physical activity was highly restricted. A total of 44 patients received low molecular weight heparin (3500 IU/d of bemiparin) subcutaneously for 6 months. The outcome measures were incidence of VTE and mortality at 3 and 6 months. RESULTS: Four patients (9.1%) died in the heparin group and 9 (20.4%) died in the control group; the difference was not statistically significant (P=.23). VTE without pulmonary embolism developed in 1 patient (2%) in each group. Slight bleeding complications appeared in 9 patients (20.4%) in the heparin group and 1 patient (2.3%) in the control group, a difference that was statistically significant (P=.015). CONCLUSIONS: Home prophylaxis with heparin does not reduce the incidence of VTE or overall mortality in patients with severe COPD.

¿Puede reducir la mortalidad de los pacientes con EPOC la profilaxis domiciliaria de la enfermedad tromboembólica venosa? / Can home prophylaxis for venous thromboembolism reduce mortality rates in patients with Chronic Obstructive Pulmonary disease?

Objetivo: La incidencia de enfermedad tromboembólica venosa (ETV) en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) oscila entre el 20 y el 60% según las series, y la mortalidad por ETV es superior en estos enfermos. Por ello suele prescribirse profilaxis con heparina a los pacientes con EPOC hospitalizados por una agudización. Sin embargo, una vez que se estabiliza su situación, se les remite a su domicilio sin dicha profilaxis, a pesar de que la escasa actividad física que les permite su enfermedad sigue constituyendo un factor de riesgo para la aparición de ETV. El objetivo de este estudio ha sido analizar si la profilaxis domiciliaria con heparina reduce la aparición de ETV y la mortalidad global en los enfermos con EPOC evolucionada. Pacientes y métodos: Se ha realizado un ensayo clínico prospectivo aleatorizado con 87 pacientes afectados de EPOC grave que precisaban oxigenoterapia domiciliaria (18 h o más al día), con una alta limitación de la actividad física. Un total de 44 sujetos recibió heparina de bajo peso molecular (HBPM; 3.500 U/día de bemiparina) por vía subcutánea durante 6 meses. Las variables estudiadas fueron la incidencia de ETV y la mortalidad a los 3 y 6 meses. Resultados: Durante el estudio fallecieron 4 pacientes del grupo que recibió HBPM (9,1%) y 9 del grupo control (20,4%); las diferencias entre ambos grupos no fueron estadísticamente significativas (p = 0,23). Presentó trombosis venosa profunda sin embolia pulmonar un paciente de cada grupo (2%). Aparecieron complicaciones hemorrágicas leves en 9 pacientes del grupo con HBPM (20,4%), frente a una en el grupo control (2,3%), diferencia que fue estadísticamente significativa (p = 0,015). Conclusiones: La profilaxis domiciliaria con heparina no reduce la aparición de ETV ni la mortalidad global en los pacientes con EPOC avanzada

Objective: The incidence of venous thromboembolism (VTE) in patients with chronic obstructive pulmonary disease (COPD) ranges from 20% to 60% in different studies and the mortality rates are higher for patients with both conditions. Heparin prophylaxis is therefore usually prescribed for COPD patients who are hospitalized for exacerbation. Once their situation becomes stable, however, they are discharged to home without prophylaxis even though the low level of physical activity their disease allows continues to put them at risk for VTE. The aim of this study was to test the efficacy of home heparin prophylaxis on reducing the incidence of VTE and on the overall mortality rate in patients with severe COPD. Patients and methods: We conducted a prospective, randomized controlled trial of 87 patients with severe COPD who required home oxygen therapy (>=18 h/d) and whose physical activity was highly restricted. A total of 44 patients received low molecular weight heparin (3500 IU/d of bemiparin) subcutaneously for 6 months. The outcome measures were incidence of VTE and mortality at 3 and 6 months. Results: Four patients (9.1%) died in the heparin group and 9 (20.4%) died in the control group; the difference was not statistically significant (P=.23). VTE without pulmonary embolism developed in 1 patient (2%) in each group. Slight bleeding complications appeared in 9 patients (20.4%) in the heparin group and 1 patient (2.3%) in the control group, a difference that was statistically significant (P=.015). Conclusions: Home prophylaxis with heparin does not reduce the incidence of VTE or overall mortality in patients with severe COPD

Pulmonary involvement in leptospirosis.

The objective of this study was to assess the incidence of pulmonary involvement in a cohort of 26 patients in whom a diagnosis of leptospirosis had been made. Seventeen of the 26 patients had respiratory symptoms. Of these 17 patients, 13 had radiographs showing pulmonary abnormality. The most frequent finding was a bilateral patchy alveolar-acinar pattern in six patients. Three patients developed acute respiratory distress syndrome and died due to multiorgan failure. Only cigarette smoking was significantly associated with respiratory involvement (odds ratio, 19.2; 95% CI, 1.7-250; P < 0.001). The results indicate that pulmonary manifestations are observed in a high percentage of patients with leptospirosis. Cigarette smoking is a risk factor for the development of pulmonary involvement in human leptospirosis.

[Characteristics of tuberculosis in a tertiary hospital during the years 1993-1996. Influence of the coinfection with HIV]. / Características de la tuberculosis en un hospital terciario durante los años 1993-1996. Influencia de la coinfección por el VIH.

To assess and compare epidemiological factors, clinical and radiological signs, laboratory results and drug resistance in patients with tuberculosis (TB) with and without AIDS. Retrospective study of TB diagnosed bacteriologically between January 1993 and December 1996 at Hospital Universitario La Fe. Annual rates were 41.7, 47.1, 34.6 and 43.8 per 100,000 inhabitants in 1993 to 1996, respectively. AIDS was present in 22.4%. TB was pulmonary in 87% and 49.4% in patients without and with AIDS, respectively. Incidence was higher in the 25 to 34 age range. Prior contact with TB patients was established in 19.2% of cases. Pulmonary TB in patients with AIDS presented with normal lung X-rays in 30.1%; 16.2% of these had positive sputum cultures. Pulmonary cavitation was evident in 32.6% of TB patients without AIDS and 6.8% of those with AIDS. Pulmonary TB was diagnosed by culture of sputum taken at the time of admission in 25.9% of non AIDS patients and in 12.4% of patients with AIDS. Extrapulmonary TB was diagnosed by culture in most cases. Such forms predominated among TB plus AIDS patients, with most cases being ganglial and urogenital. Overall drug resistance was 8.3% (7.4% non-AIDS/11.5% AIDS). Primary resistance (PR) was 6.3% and 7.1%, PR to hydrazides was 5% and 5.4%, and secondary resistance was 32.4% and 33.3%. Drug resistance in non-AIDS and AIDS patients, was associated with a history of TB and past treatment (p < 0.009), prior contact with TB patients (p < 0.004) and pulmonary cavitatin (p < 0.02). TB with AIDS tends to occur in a younger population, is often extrapulmonary or with atypical lung involvement. Drug resistance is similar in patients with and without AIDS.

[Infection by Strongyloides stercoralis in the county of Safor, Spain]. / Infección por Strongyloides stercoralis en la comarca de La Safor (Comunidad Valenciana).

BACKGROUND: Strongyloides stercoralis is an endemic nematode in tropical and subtropical regions, but almost unknown in Spain. PATIENTS AND METHODS: In order to know some epidemiological, clinical and analytic features of this infection in our area (La Safor, Valencia), we performed a prospective study for 19 months. Through the search for the parasite in feces of patients with eosinophilia, we identified 37 subjects who were studied at diagnosis and 4 months later. RESULTS: Thirty-three patients (89%) were currently, or had been agricultural workers, and thirty had worked barefooted and/or had drunk contaminated irrigation water. Twenty-three patients (62%) had a chronic or immunosuppressive diseases, and two of them on steroid treatment, developed a disseminated strongyloidiasis. Thirteen patients (35%) were asymptomatic; the rest had clinical manifestations attributed S. stercoralis, mainly digestive. Two of the patients with disseminated strongyloidiasis also had concomitant bacterial infections by Streptococcus bovis, Streptococcus faecalis and Enterobacter sp. At diagnosis, besides eosinophilia, 86.5% had raised levels of IgE. Four months later treatment, the number of eosinophils was normal and IgE levels significantly decreased. The diagnostic yield of parasitic study of feces was increased with the number of samples examined. Thiabendazole achieved erradication of the parasite in 35 patients, and the other two died because of disseminated strongyloidiasis. CONCLUSIONS: The presence of eosinophilia in patients from rural areas with subtropical climate should raise suspicion about infection by S. stercoralis, which, although sometimes is asymptomatic, may cause systemic bacterial infections in cases of hyperinfestation, specially when glucocorticoid treatment is given.

[The prognostic factors for early mortality and for total or partial gammagraphic resolution in venous thromboembolic disease]. / Factores pronósticos de la mortalidad precoz y de la resolución total o parcial gammagráfica en la enfermedad tromboembólica venosa.

Our objective was to investigate possible factors implicated in either early death from or scintigraphic resolution of pulmonary embolism. To that end we conducted a retrospective study of 116 patients with either a high likelihood of pulmonary thromboembolism (PTE) diagnosed by scintiscan or with a fair probability of PTE by scintiscan accompanied by a positive phlebograph. The images were taken upon admission, at 7 days, 10 days and 6 months. The factors analyzed were age, sex, trauma, immobility, surgery, obesity, hemiplegia, venous insufficiency, cardiopulmonary disease, neoplasia, chest X-ray and ECG alterations, D(A-a)O2 and size of perfusion defects upon admission and 7 to 10 days later. We performed single-variable analyses and multiple logical regression analyses using perfusion defect at 6 months as the dependent variable. The early mortality rate (13%) was higher in patients with neoplasms, a larger alveolar-arterial index and greater perfusion defects upon admission. Scintiscans became normal in 28%. Multivariate analysis to predict total or partial resolution at 6 months showed that size of perfusion defects at 7 to 10 days was the best predictive factor. A cutoff point was calculated by analyzing the ROC for this factor. Thus, when the defect at 7 to 10 days was equal to or greater than 1 segment, the probability of residual defects remaining after 6 months was twice as great (sensitivity 83%, specificity 57%). In conclusion, early death was more likely in PTE patients with neoplasms, larger defects upon admission and greater alveolar-arterial difference. Scintigrams showed resolution 6 months after admission in 28%. The size of perfusion defects 7 to 10 days after admission was the factor that best predicted total of partial resolution at 6 months.

[Strongyloides stercoralis infection in patients with bronchial obstructive pathology]. / Infección por Strongyloides stercoralis en pacientes con patología bronquial obstructiva.

Strongyloides stercoralis infection was hardly seen in Spain until a few years ago but has recently been shown to be fairly common in some geographic areas. In the respiratory tract this germ can cause acute bronchospasms that make diagnosis difficult, particularly in patients with underlying bronchial disease. To determine if curing S. stercoralis infection is accompanied by clinical and functional improvement in patients with bronchial obstruction, we studied the evolution of 22 infected patients: 11 with no bronchopulmonary disease and 11 with chronic airway obstruction or asthma. The following variables were assessed in both groups at the moment of diagnosis of infection and four months after cure: levels of eosinophils and total serum IgE, respiratory symptoms, steroid doses and spirometric parameters. After four months we observed a significant decrease in eosinophil (16 versus 5%) and IgE (1,600 versus 770 IU/ml) levels in both groups. The number of bronchospasms and daily steroid doses required decreased in the group with bronchial disease. No significant differences were seen in spirometric parameters, however. The improvement in respiratory symptoms, blood parameters and need for medication leads us to believe that airway inflammation decreases after the infection has been eradicated, in spite of the lack of improvement in bronchial obstruction.

[Strongyloides stercoralis infection in a cortico-dependent patient with chronic airflow obstruction]. / Infección por Strongyloides stercoralis en un paciente con obstruccion crónica al flujo aéreo corticodependiente.

We report a case of Strongyloides stercoralis infection in a male agricultural worker with corticoid dependent chronic obstructive air flow disease and bronchial hyperreactivity. The clinical picture initially involved digestive symptoms and bronchospasm resistant to steroid treatment. Diagnosis was established by demonstrating the larvae of S. stercoralis in stool. We emphasize that this infection should be suspected in patients living in endemic areas such as Spain, and describe S. stercoralis-caused respiratory manifestations that can be masked by bronchial disease.

[The diagnostic evaluation of rapid sputum technics for Pneumococcus in community-acquired pneumonia. The usefulness of Bayes theorem for clinical application]. / Evaluación diagnóstica de las técnicas rápidas del esputo frente neumococo en la neumonía adquirida en la comunidad. Utilización del teorema de Bayes para su aplicación clínica.

This study aimed to quantify the diagnostic value of immunological techniques and methods for rapid analysis of sputum for pneumococcus, using sensitivity and specificity values reported in the literature to calculate positive and negative predictive values (PPV and NPV) according to Bayes formulas. Diagnostic gains of the test are calculated and compared to pretext probability. We located articles reporting sensitivity and specificity of counterimmunoelectrophoresis (CIE), coagglutination (CoA) and latex agglutination (LA) tests. We also calculated the probability ratios for the three tests. LA achieved the best overall diagnostic utility rating. CoA had the highest PPV, whereas LA offered the highest NPV. CIE was the least useful. These three tests are more useful at intermediate levels of prevalence of pneumococcus, which coincide with estimate in our population. We conclude that LA and CoA are of greater diagnostic utility for community acquired pneumonia, as they are useful for determining prevalence as well as for deciding initial antibiotic treatment.