Interhospital Sepsis Code in Catalonia (Spain): Territorial model for initial care of patients with sepsis. / Código Sepsis Interhospitalario en Catalunya: modelo organizativo territorial para la atención inicial al paciente con sepsis.

Sepsis is a syndromic entity with high prevalence and mortality. The management of sepsis is standardized and exhibits time-dependent efficiency. However, the management of patients with sepsis is complex. The heterogeneity of the forms of presentation can make it difficult to detect and manage such cases, in the same way as differences in training, professional competences or the availability of health resources. The Advisory Commission for Patient Care with Sepsis (CAAPAS), comprising 7 scientific societies, the Emergency Medical System (SEM) and the Catalan Health Service (CatSalut), have developed the Interhospital Sepsis Code (CSI) in Catalonia (Spain). The general objective of the CSI is to increase awareness, promote early detection and facilitate initial care and interhospital coordination to attend septic patients in a homogeneous manner throughout Catalonia.

Diagnosis and treatment of catheter-related bloodstream infection: Clinical guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology and (SEIMC) and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC).

Catheter-related bloodstream infections (CRBSI) constitute an important cause of hospital-acquired infection associated with morbidity, mortality, and cost. The aim of these guidelines is to provide updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Experts in the field were designated by the two participating Societies (the Spanish Society of Infectious Diseases and Clinical Microbiology and [SEIMC] and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units [SEMICYUC]). Short-term peripheral venous catheters, non-tunneled and long-term central venous catheters, tunneled catheters and hemodialysis catheters are covered by these guidelines. The panel identified 39 key topics that were formulated in accordance with the PICO format. The strength of the recommendations and quality of the evidence were graded in accordance with ESCMID guidelines. Recommendations are made for the diagnosis of CRBSI with and without catheter removal and of tunnel infection. The document establishes the clinical situations in which a conservative diagnosis of CRBSI (diagnosis without catheter removal) is feasible. Recommendations are also made regarding empirical therapy, pathogen-specific treatment (coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp., Gram-negative bacilli, and Candida spp.), antibiotic lock therapy, diagnosis and management of suppurative thrombophlebitis and local complications.

Nationwide study on peripheral-venous-catheter-associated-bloodstream infections in internal medicine departments.

BACKGROUND: The use of peripheral venous catheters (PVCs) has increased outside intensive care units, as has the rate of PVC-associated-bloodstream infection (PVC-BSI). PVCs are widely used in internal medicine departments (IMDs), but data on the incidence of PVC-BSI and its characteristics in IMDs are scarce. AIM: To assess the incidence of PVC-BSI episodes detected in IMDs in Spain. METHODS: A one-year multi-centre prospective observational cohort study in 14 Spanish IMDs was undertaken. Adult patients admitted with at least one PVC and bacteraemia were included in the study. Demographic and clinical data were provided by local coordinators. FINDINGS: Seventy episodes of PVC-BSI were recorded, representing an overall rate of 1.64 PVC-BSI episodes/1000 IMD admissions. The mean age of patients was 67.44 (standard deviation 16.72) years. It was estimated that 25.7% of PVCs were no longer necessary. Staphylococcus aureus was the most frequently isolated micro-organism (41.7%). Phlebitis was clinically evident in 44 (62.9%) episodes, and proved to be an independent predictor of catheter insertion in emergency departments (odds ratio 5.44). The crude and attributable mortality rates were 12.9% and 5.7%, respectively. CONCLUSIONS: PVCs carry a significant risk for bacteraemia in Spanish IMDs. Phlebitis is not always clinically evident in patients with bacteraemia in this population. The study findings support the need for educational and interventional preventive measures in both IMDs and emergency departments to reduce the rate of PVC-BSI and associated comorbidities, and costs.

Peripheral venous catheter, a dangerous weapon. Key points to improve its use.

Catheter-related bacteremia is one of the most important causes of nosocomial infection. Is associated to high rates of morbidity and mortality, including an economic burden. Peripheral venous catheter bacteremia is a leading cause of nosocomial infection in internal medicine departments. In this article, we review some important key points to improve its use and avoid infections.

2016 Expert consensus document on prevention, diagnosis and treatment of short-term peripheral venous catheter-related infections in adult.

The use of endovascular catheters is a routine practice in secondary and tertiary care level hospitals. Short peripheral catheters have been found to be associated with the risk of nosocomial bacteremia resulting in morbidity and mortality. Staphyloccus aureus is mostly associated with peripheral catheter insertion. This Consensus Document has been elaborated by a panel of experts of the Spanish Society of Cardiovascular Infections in cooperation with experts from the Spanish Society of Internal Medicine, Spanish Society of Chemotherapy and Spanish Society of Thoracic-Cardiovascular Surgery and aims at define and establish the norm for management of short duration peripheral vascular catheters. The document addresses the indications for insertion, catheter maintenance and registry, diagnosis and treatment of infection, indications for removal and stresses on continuous education as a driver for quality. Implementation of this norm will allow uniformity in usage thus minimizing the risk of infection and its complications.

Nationwide study on the use of intravascular catheters in internal medicine departments.

BACKGROUND: The use of intravascular catheters (IVCs) in intensive care units (ICUs) has been well assessed in recent years. However, a high proportion of these devices are placed in patients outside the ICU, particularly in internal medicine departments (IMDs), where data on the quality of care are scarce. AIM: To assess the use and management of IVCs in IMDs in Spain. METHODS: We performed a point prevalence study of all adult inpatients on 47 IMDs from hospitals of different sizes on one day in June 2013. A local co-ordinator was appointed to assess patients and collect data from each site. FINDINGS: Out of the 2080 adult patients hospitalized on the study day, 1703 (81.9%) had one or more IVCs (95.4% of which were peripheral devices). Infection was detected at the insertion site in 92 catheters (5.0%); 87 patients (5.2%) had signs of sepsis, but only one case was considered to be catheter-related. The local co-ordinators estimated that 19% of the catheters in place were no longer necessary. A daily record of the need for a catheter was available in only 40.6% of cases. CONCLUSION: Our study shows clear opportunities for improvement regarding catheter use and care in Spanish IMDs. Strategies similar to those applied in ICUs should be implemented in IMDs.

Mortality among methicillin-resistant Staphylococcus aureus carriers in long-term care facilities.

INTRODUCTION: Little is known about the natural course of patients with chronic stable illnesses colonized with methicillin-resistant Staphylococcus aureus (MRSA). The aim is to determine the impact of MRSA colonization in mortality among long-term health care facility (LTHCF) residents. METHOD: A multicenter, prospective, observational study was designed. Residents in 4 LTHCFs were classified according to MRSA carriage status and followed for 12 months. Treatment consisted of 5 days of nasal mupirocin in MRSA carriers. RESULTS: Ninety-three MRSA-carriers among 413 residents were identified. Thirty-one MRSA-colonized patients died during the study period, 11 of whom from an infectious disease. Independent predictors of their higher mortality rates included heart failure, current neoplasm, MRSA carriage and COPD at 3 months and these same factors plus stroke, Bar-thel index <40, pressure ulcers, and older age at 12 months. MRSA-persistence was 35% and 62.5% at 3 and 12 months, respectively. CONCLUSIONS: MRSA colonization among frail LTHCFs residents is highly prevalent, and is associated with higher mortality. Despite treatment of MRSA carriers, many remained colonized. Factors that promote persistence of MRSA colonization, and the impact of their modification on mortality rates in these patients, need further investigation.

Prevalence and risk factors for meticillin-resistant Staphylococcus aureus in an acute care hospital and long-term care facilities located in the same geographic area.

UNLABELLED: To determine the prevalence and risk factors (RF) for methicillin-resistant Staphylococcus aureus (MRSA) during stay in 1 acute care hospital (ACH) and 4 long-term care facilities (LTCF). After obtaining the informed consent, nasal and skin ulcer swabs were taken and a survey was conducted to determine RF for MRSA. Six hundred and ninety nine patients were included, 413 LTCF and 286 ACH patients and MRSA prevalence were 22.5% and 7.3% respectively. MRSA was located in the nares, skin ulcers, and in both in 61.4%, 21.1%, and 17.5%. Among MRSA carriers, 81% of the ACH and 66.7% of the LTCF patients were only colonized. The multivariate analysis for the ACH revealed the following factors to be associated with MRSA: referral from an LTCF (OR 4.84), pressure ulcers (OR 4.32), a Barthel score < 60 (OR 2.60), and being male (OR 5.21). For the LTCF: urinary catheterisation (OR 3.53), pressure ulcers (OR 2.44), other skin lesions (OR 2.64), antibiotic treatment in ≤ 6 months, (OR 2.23), previous MRSA colonization (OR 2.15), and a Barthel score <20 (OR 1.28). Molecular typing identified 2 predominant clones Q, P, present in all centres. No relationship was found between clones and antibiotic susceptibility. IN CONCLUSION: MRSA prevalence is high in all centres but is 3 times greater in LTCF. The risk factors most strongly associated with MRSA were pressure ulcers and a stay in an LTCF. We propose preventive isolation in these cases.

The management of pneumonia in internal medicine

La neumonía acarrea una importante carga de trabajo en los servicios de medicina interna. Puesto que los pacientes suelen ser de edad avanzada y presentan múltiples enfermedades comórbidas, su tratamiento es difícil. Además, en este contexto, la interpretación de las guías publicadas, al igual que la adhesión a ellas, está lejos de ser clara. Describimos la opinión de 43 especialistas en medicina interna, especialmente interesados en las enfermedades infecciosas, que asistieron a la XXXII Conferencia Nacional de la Sociedad Española de Medicina Interna, celebrada en 2011, y a los que se formularon preguntas sobre los principales problemas relacionados con el manejo de la neumonía en los servicios de medicina interna, es decir, su clasificación, los criterios de ingreso, examen microbiológico, manejo terapéutico, normas de alta y prevención de futuros episodios. Para cada enunciado, redactado por 4 investigadores, los participantes tenían que elegir entre 2 opciones. En muchos casos no se alcanzó un consenso. Los problemas más controvertidos se relacionaron con el reconocimiento y el manejo de la neumonía asociada a la asistencia sanitaria (NAAS). La mayoría de los participantes conocían las diferencias con respecto a las enfermedades subyacentes, la distribución etiológica y el desenlace de la NAAS, comparado con la neumonía adquirida en la comunidad, pero solo una minoría estuvo de acuerdo en tratar la NAAS como una neumonía hospitalaria, según lo sugerido por algunas guías. En el manejo de la NAAS la opción preferida por los expertos en medicina interna fue establecer una estrategia clínica paciente a paciente(AU)

Pneumonia generates a high workload for internal medicine departments. Management of this disease is challenging, because patients are usually elderly and have multiple comorbid conditions. Furthermore, the interpretation and adherence to guidelines are far from clear in this setting. We report the opinion of 43 internists especially interested in infectious diseases that were questioned at the 2011 XXXII National Conference of Spanish Society of Internal Medicine about the main issues involved in the management of pneumonia in the internal medicine departments, namely, classification, admission criteria, microbiological workup, therapeutic management, discharge policy, and prevention of future episodes. Participants were asked to choose between 2 options for each statement by 4 investigators. Consensus could not be reached in many cases. The most controversial issues concerned recognition and management of healthcare-associated pneumonia (HCAP). Most participants were aware of the differences in terms of underlying diseases, etiological distribution, and outcome of HCAP compared with community-acquired pneumonia, but only a minority agreed to manage HCAP as hospital-acquired pneumonia, as suggested by some guidelines. A clinical patient-to-patient approach proved to be the option preferred by internists in the management of HCAP(AU)

The management of pneumonia in internal medicine.

Pneumonia generates a high workload for internal medicine departments. Management of this disease is challenging, because patients are usually elderly and have multiple comorbid conditions. Furthermore, the interpretation and adherence to guidelines are far from clear in this setting. We report the opinion of 43 internists especially interested in infectious diseases that were questioned at the 2011 XXXII National Conference of Spanish Society of Internal Medicine about the main issues involved in the management of pneumonia in the internal medicine departments, namely, classification, admission criteria, microbiological workup, therapeutic management, discharge policy, and prevention of future episodes. Participants were asked to choose between 2 options for each statement by 4 investigators. Consensus could not be reached in many cases. The most controversial issues concerned recognition and management of healthcare-associated pneumonia (HCAP). Most participants were aware of the differences in terms of underlying diseases, etiological distribution, and outcome of HCAP compared with community-acquired pneumonia, but only a minority agreed to manage HCAP as hospital-acquired pneumonia, as suggested by some guidelines. A clinical patient-to-patient approach proved to be the option preferred by internists in the management of HCAP.

The management of pneumonia in internal medicine.

Pneumonia generates a high workload for internal medicine departments. Management of this disease is challenging, because patients are usually elderly and have multiple comorbid conditions. Furthermore, the interpretation and adherence to guidelines are far from clear in this setting. We report the opinion of 43 internists especially interested in infectious diseases that were questioned at the 2011 XXXII National Conference of Spanish Society of Internal Medicine about the main issues involved in the management of pneumonia in the internal medicine departments, namely, classification, admission criteria, microbiological workup, therapeutic management, discharge policy, and prevention of future episodes. Participants were asked to choose between 2 options for each statement by 4 investigators. Consensus could not be reached in many cases. The most controversial issues concerned recognition and management of healthcare-associated pneumonia (HCAP). Most participants were aware of the differences in terms of underlying diseases, etiological distribution, and outcome of HCAP compared with community-acquired pneumonia, but only a minority agreed to manage HCAP as hospital-acquired pneumonia, as suggested by some guidelines. A clinical patient-to-patient approach proved to be the option preferred by internists in the management of HCAP.

Pneumonia treated in the internal medicine department: focus on healthcare-associated pneumonia.

Patients with pneumonia treated in the internal medicine department (IMD) are often at risk of healthcare-associated pneumonia (HCAP). The importance of HCAP is controversial. We invited physicians from 72 IMDs to report on all patients with pneumonia hospitalized in their department during 2 weeks (one each in January and June 2010) to compare HCAP with community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). We analysed 1002 episodes of pneumonia: 58.9% were CAP, 30.6% were HCAP and 10.4% were HAP. A comparison between CAP, HCAP and HAP showed that HCAP patients were older (77, 83 and 80.5 years; p < 0.001), had poorer functional status (Barthel 100, 30 and 65; p < 0.001) and had more risk factors for aspiration pneumonia (18, 50 and 34%; p < 0.001). The frequency of testing to establish an aetiological diagnosis was lower among HCAP patients (87, 72 and 79; p < 0.001), as was adherence to the therapeutic recommendations of guidelines (70, 23 and 56%; p < 0.001). In-hospital mortality increased progressively between CAP, HCAP and HAP (8, 19 and 27%; p < 0.001). Streptococcus pneumoniae was the main pathogen in CAP and HCAP. Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) caused 17 and 12.3% of HCAP. In patients with a confirmed aetiological diagnosis, the independent risk factors for pneumonia due do difficult-to-treat microorganisms (Enterobacteriaceae, P. aeruginosa or MRSA) were HCAP, chronic obstructive pulmonary diseases and higher Port Severity Index. Our data confirm the importance of maintaining high awareness of HCAP among patients treated in IMDs, because of the different aetiologies, therapy requirements and prognosis of this population.

[Malaria prophylaxis in the traveler]. / Profilaxis de la malaria en el viajero.

Malaria is a preventable and curable disease. The risk zones are those tropical and subtropical regions of the countries with endemic malaria. These countries are visited by 125 million international tourists yearly and it is estimated that up to 30,000 fall sick with malaria. Prevention is done by: preventing transmission (using mosquito repellent, mosquito nets, etc.) and by preventing the disease by chemoprophylaxis. The latter aims to reduce the risk of suffering severe malaria, basically that produced by P. falciparum. It consists in the administration of antimalaria drugs before, during and after the trip. The choice of antimalaria drug will depend on the individual factors (allergies, contraindications, etc.) and mainly on the resistance of P. falciparum to these drugs. In areas with sensitivity to chloroquine, this should be the drug of choice and in those with resistances, three drugs have been recommended by both the CDC and WHO: Atovaquone/proguanil, Doxycycline and Mefloquine.

Profilaxis de la malaria en el viajero / Malaria prophylaxis in the traveler

La malaria es una enfermedad prevenible y curable. Las zonas de riesgo son aquellas regiones tropicales y subtropicales de los países con malaria endémica. Países visitados por más de 125 millones de turistas internacionales anualmente, de los cuales se estima que hasta unos 30.000 enfermarán de paludismo. La prevención recae en: prevenir la transmisión (usar repelentes de mosquitos, mosquiteras, etc.) y prevenir la enfermedad mediante la quimioprofilaxis. Esta última tiene como objetivo reducir el riesgo de padecer el paludismo grave, básicamente el producido por Plasmodium falciparum. Consiste en la administración de fármacos antimaláricos antes, durante y un tiempo después del viaje. La elección del antimalárico dependerá de factores individuales (alergias, contraindicaciones, etc.) y, principalmente, de la resistencia de P. falciparum a dichos fármacos. En las áreas con sensibilidad a cloroquina, este va a ser el fármaco de elección y, en las que haya resistencia, existen 3 fármacos recomendados tanto por los Centers for Disease Control and Prevention (CDC, ‘Centros para el Control y la Prevención de las Enfermedades’) como por la OMS: atovaquona/proguanil, doxiciclina y mefloquina(AU)

Malaria is a preventable and curable disease. The risk zones are those tropical and subtropical regions of the countries with endemic malaria. These countries are visited by 125 million international tourists yearly and it is estimated that up to 30,000 fall sick with malaria. Prevention is done by: preventing transmission (using mosquito repellent, mosquito nets, etc.) and by preventing the disease by chemoprophylaxis. The latter aims to reduce the risk of suffering severe malaria, basically that produced by P. falciparum. It consists in the administration of antimalaria drugs before, during and after the trip. The choice of antimalaria drug will depend on the individual factors (allergies, contraindications, etc.) and mainly on the resistance of P. falciparum to these drugs. In areas with sensitivity to chloroquine, this should be the drug of choice and in those with resistances, three drugs have been recommended by both the CDC and WHO: Atovaquone/proguanil, Doxycycline and Mefloquine(AU)

[Multicenter national survey on infection management in patients with penicillin allergy]. / Encuesta multicéntrica nacional sobre el manejo de la infección en pacientes alérgicos a betalactámicos.

INTRODUCTION: Beta-lactam antibiotics are widely prescribed to treat many infections because of efficacy, spectrum and safety. Their use is limited in patients with resistant microbial agents and in those with a history of penicillin allergy (HPA) because of cross-reactivity risk. Accurate clinical assessment of possible HPA requires specialized resources not always available in clinical practice. We intended to get to know the opinion of Spanish physicians about frequency and methods of evaluation of the patients with HPA as well as the preferences in the use of antimicrobial alternatives for common infectious diseases in patients with HPA. METHODS: Multicentric cross-sectional descriptive study ran by the Infectious Diseases Study Group of the Spanish Society for Internal Medicine based on the accomplishment of a survey of 10 questions of opinion to specialist doctors who work in Spanish medical centers. RESULTS: A total of 311 doctors responded to the survey (92.2% Internal Medicine specialists) distributed by all the Spanish territory. An average of 10.7% of patients self-reported having HPA although only an average of 10.8% of them gave documentation on the matter. Patients were sent for specific allergy tests in an average of 33.6%. Desensitization treatments were performed in 4.3% of cases. The preferences for alternative antibiotic therapy to beta-lactam widely varied according to the infectious picture and the communitarian or nosocomial origin, and they included quinolones, macrolides, glycopeptides, lincosamides, oxazolidinones and tigecycline. CONCLUSIONS: Perception about frequency and evaluation of patients with HPA is very variable, but in more than half the cases it is above 10% of the patients. Yet, only one third are sent for in-depth study for allergy confirmation, and less than 5% are desensitized. Nosocomial infections and the possibility of multiresistant bacteria make substantially difficult the management of patients with HPA.

Encuesta multicéntrica nacional sobre el manejo de la infección en pacientes alérgicos a betalactámicos / Multicenter national survey on infection management in patients with penicillin allergy

Introducción. Los antibióticos betalactámicos son los másampliamente usados por su eficacia, espectro y seguridad. Suuso se encuentra limitado por la resistencia bacteriana y porlas reacciones adversas, fundamentalmente hipersensibilidad.La correcta valoración de una posible alergia a betalactámicos(ABLA) requiere medios especializados no siempre disponiblesen la práctica clínica. Pretendemos conocer la opiniónde los clínicos españoles en cuanto a la frecuencia y métodosde evaluación de los pacientes con ABLA así como las preferenciasen el uso de antimicrobianos alternativos a betalactámicospara el manejo de cuadros infecciosos habituales.Métodos. Estudio descriptivo transversal multicéntricopromovido por el Grupo de Trabajo en Enfermedades Infecciosas(GTEI) de la Sociedad Española de Medicina Interna(SEMI) basado en la realización de una encuesta de 10 preguntasde opinión a médicos especialistas que trabajan encentros médicos españoles.Resultados. Un total de 311 médicos respondieron a laencuesta (92,2 % médicos especialistas en medicina interna)repartidos por todo el territorio español. Una media del10,7% de los pacientes atendidos se declara con ABLA aunquesólo una media del 10,8% de los mismos aporta documentaciónal respecto. Los pacientes son remitidos paraestudio alergológico en una media del 33,6 %. Los tratamientosde desensibilización se realizan en un 4,3% de casos.La preferencia por el uso de antibióticos alternativos abetalactámicos varía ampliamente según el cuadro infecciosoy el origen comunitario o nosocomial e incluye quinolonas,macrólidos, glucopéptidos, lincosamidas, oxazolidinonasy tigeciclina (AU)

Introduction. Beta-lactam antibiotics are widely prescribedto treat many infections because of efficacy,spectrum and safety. Their use is limited in patients withresistant microbial agents and in those with a history ofpenicillin allergy (HPA) because of cross-reactivity risk.Accurate clinical assessment of possible HPA requiresspecialized resources not always available in clinicalpractice. We intended to get to know the opinion ofSpanish physicians about frequency and methodsof evaluation of the patients with HPA as well as thepreferences in the use of antimicrobial alternatives forcommon infectious diseases in patients with HPA.Methods. Multicentric cross-sectional descriptivestudy ran by the Infectious Diseases Study Group of theSpanish Society for Internal Medicine based on the accomplishmentof a survey of 10 questions of opinion tospecialist doctors who work in Spanish medical centers.Results. A total of 311 doctors responded to the survey(92.2% Internal Medicine specialists) distributed by allthe Spanish territory. An average of 10.7% of patientsself-reported having HPA although only an average of10.8 % of them gave documentation on the matter. Patientswere sent for specific allergy tests in an average of33.6 %. Desensitization treatments were performed in4.3 % of cases. The preferences for alternative antibiotictherapy to beta-lactan widely varied according to the infectiouspicture and the communitarian or nosocomialorigin, and they included quinolones, macrolides, glycopeptides,lincosamides, oxazolidinones and tigecycline (AU)

Sporadic and epidemic community legionellosis: two faces of the same illness.

The present study compares the risk factors, presentation and outcome of community-acquired Legionella pneumophila pneumonia in 138 sporadic-case patients (1994-2004) and 113 outbreak-case patients (2002) treated in two hospitals in Catalonia (Spain) since urinary antigen assays were adopted. Univariate and multivariate analysis were performed to compare epidemiological and clinical features, blood chemistry values, radiological findings and outcome of sporadic and epidemic legionnaires' disease. Univariate analysis showed that male sex, chronic lung disease, HIV infection and immunosuppressive therapy prevailed in sporadic cases. Presentation with respiratory symptoms, confusion and blood chemistry alterations, such as hyponatraemia, aspartate aminotransferase and blood urea nitrogen elevation, and partial pressure of oxygen P(O)(2) <7.98 KPa (60 mmHg) were also more frequent in sporadic cases, while headache prevailed in outbreak cases. Sporadic cases had a greater delay in treatment, were more severe and had a worse outcome than epidemic cases. Multivariate analysis showed significant differences in sex, chronic lung disease, HIV infection and headache. The clinical and outcome differences between the two groups may be explained by the detection of milder forms of legionnaires' disease, the earlier treatment and the lower severity of underlying disease in the outbreak cases.