[Description of an intervention to prevent pressure-induced skin lesions caused by personal protective equipment (PPE) during the care of patients with COVID-19]. / Descripción de una intervención para prevenir lesiones cutáneas por presión provocadas por los equipos de protección personal (EPIs) durante la atención de pacientes con COVID-19.

OBJECTIVE: To describe a strategy designed to avoid pressure-related skin lesions related to the use of personal protective equipment (PPE). METHODS: This was a prospective descriptive observational study. STUDY POPULATION: healthcare professionals at the Parc Salut Mar (Barcelona) who used PPE for protection against COVID-19 between March 30 and June 15, 2020. INTERVENTION: Each professional was provided with an individual kit to prevent PPE-induced lesions, friction, or moisture. A multidisciplinary surveillance team was deployed for the early detection of these adverse events. RESULTS: Individual kits were provided to 1044 professionals, 32 of whom were scheduled for in-person medical assessments. Six participants (0.57%) developed Stage III or IV pressure ulcers, 24 (2.3%) had dermatitis, folliculitis, eczema and two participants did not show for their appointments. The overall rate of pressure ulcers was 0.57%; for dermatitis it was 2.3%. CONCLUSIONS: The use of preventive measures appears to be effective in preventing facial pressure ulcers induced by EPIs among healthcare professionals. Our resultsalso underscore the importance of expanding preventive measures to include not only pressure ulcers but also dermatitis.

Objetivos: Describir los resultados de una estrategia diseñada para evitar lesiones cutáneas por presión relacionadas con la utilización de los equipos de protección individual (EPIs). Metodología: Estudio descriptivo observacional prospectivo realizado entre marzo y junio de 2020 en profesionales del Parc de Salut Mar (PSMAR) que utilizaron EPIs en áreas de pacientes diagnosticados de COVID-19. Un servicio de vigilancia multidisciplinar se activó con el fin de realizar una detección precoz. Se suministró de forma individualizada a 1044 profesionales materiales para prevención de lesiones por presión, fricción y humedad de los EPIs sobre la piel de la cara. Resultados: De todos los profesionales, 32 fueron citados para una valoración presencial por lesiones: 6 presentaron úlceras por presión en estadios III y IV, 24 dermatitis, foliculitis y eczemas. La tasa de presentación de úlceras fue del 0,57% y la de dermatitis del 2,30% de la población de estudio. Conclusión: Los resultados de la aplicación de las medidas especificadas indican que han sido eficaces para prevenir úlceras por presión en la región de la cara provocadas por los EPIs. La adopción de medidas de prevención no solo para prevenir ulceras por presión sino para la prevención de dermatitis se hacen imprescindibles en situaciones en las que se requiere el uso continuado de EPIs en la región de la cara.

Incremental cost of nosocomial bacteremia according to the focus of infection and antibiotic sensitivity of the causative microorganism in a university hospital.

To estimate the incremental cost of nosocomial bacteremia according to the causative focus and classified by the antibiotic sensitivity of the microorganism.Patients admitted to Hospital del Mar in Barcelona from 2005 to 2012 were included. We analyzed the total hospital costs of patients with nosocomial bacteremia caused by microorganisms with a high prevalence and, often, with multidrug-resistance. A control group was defined by selecting patients without bacteremia in the same diagnosis-related group.Our hospital has a cost accounting system (full-costing) that uses activity-based criteria to estimate per-patient costs. A logistic regression was fitted to estimate the probability of developing bacteremia (propensity score) and was used for propensity-score matching adjustment. This propensity score was included in an econometric model to adjust the incremental cost of patients with bacteremia with differentiation of the causative focus and antibiotic sensitivity.The mean incremental cost was estimated at &OV0556;15,526. The lowest incremental cost corresponded to bacteremia caused by multidrug-sensitive urinary infection (&OV0556;6786) and the highest to primary or unknown sources of bacteremia caused by multidrug-resistant microorganisms (&OV0556;29,186).This is one of the first analyses to include all episodes of bacteremia produced during hospital stays in a single study. The study included accurate information about the focus and antibiotic sensitivity of the causative organism and actual hospital costs. It provides information that could be useful to improve, establish, and prioritize prevention strategies for nosocomial infections.

Characterization and rapid control of a vancomycin-resistant Enterococcus faecium (VREF) outbreak in a renal transplant unit in Spain: The environment matters / Caracterización y control rápido de un brote de Enterococcus faecium resistente a vancomicina en una unidad de trasplantados renales en España: el ambiente importa

OBJECTIVE: To describe a clonal outbreak due to vancomycin-resistant Enterococcus faecium (VREF) in the nephrology and renal transplant unit of a tertiary teaching hospital in Barcelona, Spain, and to highlight how active patient and environment surveillance cultures, as well as prompt and directed intervention strategies, mainly environmental, helped to successfully bring it under control. PATIENTS AND METHODS: A study was conducted on patients admitted to the nephrology ward with any culture positive for VREF over a 6-month period (August 2012-January 2013). Based on the identification of a clonal link between the isolates, weekly rectal screening using swabs was implemented for all patients, as well as environmental cultures and cleaning of medical equipment and the ward. VREF isolates were identified by MicroScan and confirmed by Etest. Bacterial identification was confirmed by MALDI-TOF MS. The presence of van genes, and esp and hyl virulence genes was determined using PCR. The clonal relationship between the isolates was studied first with DiversiLab (bioMérieux), and then by PFGE-Smal and MLST. A two-tier sequence of infection control measures was implemented. RESULTS: During the study period, VREF was isolated from 13 patients. All cases were colonized with no criteria for infection. VREF isolates were also extensively recovered from the environment and medical equipment. Isolates carried the vanA gene, and were multidrug-resistant, including high-level resistance (MIC >16mg/L) to vancomycin and teicoplanin. Molecular analysis showed that all VREF isolates belonged to sequence type 17 (ST17) carrying hyl virulence genes. After implementing infection control measures in a two-tier sequence, and reinforcing particularly environmental and medical equipment cleaning, no further cases were detected in the follow-up year. CONCLUSION: A clonal outbreak of VREF-ST17 involving only colonization is reported. The prompt implementation of aggressive infection control measures in patients and the environment was effective in controlling the outbreak and avoided the potential emergence of infection among patients

OBJETIVO: Describir un brote clonal de Enterococcus faecium resistente a vancomicina (VREF) en la unidad de trasplante renal de un hospital universitario en Barcelona (España) y destacar que los controles ambientales, así como las estrategias de intervención dirigidas y tempranas, principalmente ambientales, fueron suficientes para controlar el brote. PACIENTES Y MÉTODOS: Se estudiaron todos los pacientes ingresados en la unidad de nefrología con un cultivo positivo para VREF en un periodo de 6 meses (Agosto de 2012 a Enero de 2013). Basados en la identificación de una relación clonal entre las cepas, se implementaron frotis rectales de cribado para todos los pacientes, así como frotis ambientales y limpieza de todo el material médico y de la unidad. Se identificaron las cepas de VREF por MicroScan y se confirmaron con Etest. La identificación bacteriana se confirmó con MALDI-TOF MS. La presencia de genes van, y de genes de virulencia esp y hyl, se investigó por PCR. La relación clonal entre las cepas se estudió con DiversiLab (bioMérieux), y después con PFGE-Smal y MLST. RESULTADOS: Durante el periodo estudiado, se aislaron cepas de VREF de 13 pacientes. Todos fueron casos de colonización sin casos de infección. Se aislaron numerosas cepas del ambiente y del equipo médico. Las cepas presentaban el gen VanA y eran multirresistentes. El análisis molecular mostró que todas las cepas pertenecían a la secuencia tipo17 (ST17), portando genes de virulencia hyl. Tras la implementación de medidas de control de infección de 2 niveles, e incrementando sobretodo la limpieza del ambiente y del equipo médico, no se detectaron nuevos casos en el año posterior. CONCLUSIÓN: Se informa de un brote clonal de VREF-ST17. La pronta implementación de medidas agresivas de control de infección en pacientes y en el ambiente fue efectiva para el control del brote

Characterization and rapid control of a vancomycin-resistant Enterococcus faecium (VREF) outbreak in a renal transplant unit in Spain: The environment matters.

OBJECTIVE: To describe a clonal outbreak due to vancomycin-resistant Enterococcus faecium (VREF) in the nephrology and renal transplant unit of a tertiary teaching hospital in Barcelona, Spain, and to highlight how active patient and environment surveillance cultures, as well as prompt and directed intervention strategies, mainly environmental, helped to successfully bring it under control. PATIENTS AND METHODS: A study was conducted on patients admitted to the nephrology ward with any culture positive for VREF over a 6-month period (August 2012-January 2013). Based on the identification of a clonal link between the isolates, weekly rectal screening using swabs was implemented for all patients, as well as environmental cultures and cleaning of medical equipment and the ward. VREF isolates were identified by MicroScan and confirmed by Etest. Bacterial identification was confirmed by MALDI-TOF MS. The presence of van genes, and esp and hyl virulence genes was determined using PCR. The clonal relationship between the isolates was studied first with DiversiLab (bioMérieux), and then by PFGE-Smal and MLST. A two-tier sequence of infection control measures was implemented. RESULTS: During the study period, VREF was isolated from 13 patients. All cases were colonized with no criteria for infection. VREF isolates were also extensively recovered from the environment and medical equipment. Isolates carried the vanA gene, and were multidrug-resistant, including high-level resistance (MIC >16mg/L) to vancomycin and teicoplanin. Molecular analysis showed that all VREF isolates belonged to sequence type 17 (ST17) carrying hyl virulence genes. After implementing infection control measures in a two-tier sequence, and reinforcing particularly environmental and medical equipment cleaning, no further cases were detected in the follow-up year. CONCLUSION: A clonal outbreak of VREF-ST17 involving only colonization is reported. The prompt implementation of aggressive infection control measures in patients and the environment was effective in controlling the outbreak and avoided the potential emergence of infection among patients.

Impacto económico de las bacteriemias nosocomiales. Comparación de tres metodologías de cálculo / Economic impact of nosocomial bacteraemia. A comparison of three calculation methods

INTRODUCCIÓN: El coste incremental que comportan las bacteriemias nosocomiales (BN) se utiliza como medida del impacto de estas infecciones. Los métodos tradicionales de cálculo de coste sobrestiman este incremento al no contemplar variables confusoras. El objetivo de este trabajo es comparar 3 metodologías de cálculo del coste incremental de la BN para corregir los sesgos presentes en análisis previos. MÉTODOS: Se compararon los pacientes que presentaron algún episodio de BN entre 2005 y 2007, con los pacientes con la misma patología sin BN. Los microorganismos causantes se agruparon según la tinción Gram y según si la bacteriemia era monomicrobiana o polimicrobiana, o producida por un hongo. Se compararon 3 métodos de cálculo: 1) estratificación por patología; 2) ajuste econométrico multivariante mediante un modelo lineal generalizado (MLG), y 3) un propensity score matching (PSM) antes del análisis multivariante para controlar los sesgos. RESULTADOS: Se analizaron 640 hospitalizaciones con BN y 28.459 sin BN; el coste medio observado fue de 24.515 € y 4.851,6 €, respectivamente. En la estratificación por patología, el coste incremental medio estimado fue de 14.735 €, el grupo de microorganismos que ocasionó menor coste incremental fue el de grampositivos, con 10.051€. En el MLG el coste incremental medio estimado fue de 20.922 €, mientras que utilizando PSM se estimó un coste incremental medio de 11.916 €. En las 3 estimaciones hay diferencias importantes según el grupo de microorganismos. CONCLUSIONES: Utilizar metodologías más elaboradas mejora el ajuste en este tipo de estudios e incrementa el valor de los resultados obtenidos

INTRODUCTION: The excess cost associated with nosocomial bacteraemia (NB) is used as a measurement of the impact of these infections. However, some authors have suggested that traditional methods overestimate the incremental cost due to the presence of various types of bias. The aim of this study was to compare three assessment methods of NB incremental cost to correct biases in previous analyses. METHODS: Patients who experienced an episode of NB between 2005 and 2007 were compared with patients grouped within the same All Patient Refined-Diagnosis-Related Group (APR-DRG) without NB. The causative organisms were grouped according to the Gram stain, and whether bacteraemia was caused by a single or multiple microorganisms, or by a fungus. Three assessment methods are compared: stratification by disease; econometric multivariate adjustment using a generalised linear model (GLM); and propensity score matching (PSM) was performed to control for biases in the econometric model. RESULTS: The analysis included 640 admissions with NB and 28,459 without NB. The observed mean cost was €24,515 for admissions with NB and €4,851.6 for controls (without NB). Mean incremental cost was estimated at €14,735 in stratified analysis. Gram positive microorganism had the lowest mean incremental cost, €10,051. In the GLM, mean incremental cost was estimated as €20,922, and adjusting with PSM, the mean incremental cost was €11,916. The three estimates showed important differences between groups of microorganisms. CONCLUSIONS: Using enhanced methodologies improves the adjustment in this type of study and increases the value of the results

Cost Attributable to Nosocomial Bacteremia. Analysis According to Microorganism and Antimicrobial Sensitivity in a University Hospital in Barcelona.

AIM: To calculate the incremental cost of nosocomial bacteremia caused by the most common organisms, classified by their antimicrobial susceptibility. METHODS: We selected patients who developed nosocomial bacteremia caused by Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, or Pseudomonas aeruginosa. These microorganisms were analyzed because of their high prevalence and they frequently present multidrug resistance. A control group consisted of patients classified within the same all-patient refined-diagnosis related group without bacteremia. Our hospital has an established cost accounting system (full-costing) that uses activity-based criteria to analyze cost distribution. A logistic regression model was fitted to estimate the probability of developing bacteremia for each admission (propensity score) and was used for propensity score matching adjustment. Subsequently, the propensity score was included in an econometric model to adjust the incremental cost of patients who developed bacteremia, as well as differences in this cost, depending on whether the microorganism was multidrug-resistant or multidrug-sensitive. RESULTS: A total of 571 admissions with bacteremia matched the inclusion criteria and 82,022 were included in the control group. The mean cost was € 25,891 for admissions with bacteremia and € 6,750 for those without bacteremia. The mean incremental cost was estimated at € 15,151 (CI, € 11,570 to € 18,733). Multidrug-resistant P. aeruginosa bacteremia had the highest mean incremental cost, € 44,709 (CI, € 34,559 to € 54,859). Antimicrobial-susceptible E. coli nosocomial bacteremia had the lowest mean incremental cost, € 10,481 (CI, € 8,752 to € 12,210). Despite their lower cost, episodes of antimicrobial-susceptible E. coli nosocomial bacteremia had a major impact due to their high frequency. CONCLUSIONS: Adjustment of hospital cost according to the organism causing bacteremia and antibiotic sensitivity could improve prevention strategies and allow their prioritization according to their overall impact and costs. Infection reduction is a strategy to reduce resistance.

[Economic impact of nosocomial bacteraemia. A comparison of three calculation methods]. / Impacto económico de las bacteriemias nosocomiales. Comparación de tres metodologías de cálculo.

INTRODUCTION: The excess cost associated with nosocomial bacteraemia (NB) is used as a measurement of the impact of these infections. However, some authors have suggested that traditional methods overestimate the incremental cost due to the presence of various types of bias. The aim of this study was to compare three assessment methods of NB incremental cost to correct biases in previous analyses. METHODS: Patients who experienced an episode of NB between 2005 and 2007 were compared with patients grouped within the same All Patient Refined-Diagnosis-Related Group (APR-DRG) without NB. The causative organisms were grouped according to the Gram stain, and whether bacteraemia was caused by a single or multiple microorganisms, or by a fungus. Three assessment methods are compared: stratification by disease; econometric multivariate adjustment using a generalised linear model (GLM); and propensity score matching (PSM) was performed to control for biases in the econometric model. RESULTS: The analysis included 640 admissions with NB and 28,459 without NB. The observed mean cost was €24,515 for admissions with NB and €4,851.6 for controls (without NB). Mean incremental cost was estimated at €14,735 in stratified analysis. Gram positive microorganism had the lowest mean incremental cost, €10,051. In the GLM, mean incremental cost was estimated as €20,922, and adjusting with PSM, the mean incremental cost was €11,916. The three estimates showed important differences between groups of microorganisms. CONCLUSIONS: Using enhanced methodologies improves the adjustment in this type of study and increases the value of the results.

Eosinophil count and neutrophil-lymphocyte count ratio as prognostic markers in patients with bacteremia: a retrospective cohort study.

INTRODUCTION: There is scarce evidence on the use of eosinophil count as a marker of outcome in patients with infection. The aim of this study was to evaluate whether changes in eosinophil count, as well as the neutrophil-lymphocyte count ratio (NLCR), could be used as clinical markers of outcome in patients with bacteremia. METHODS: We performed a retrospective study of patients with a first episode of community-acquired or healthcare-related bacteremia during hospital admission between 2004 and 2009. A total of 2,311 patients were included. Cox regression was used to analyze the behaviour of eosinophil count and the NLCR in survivors and non-survivors. RESULTS: In the adjusted analysis, the main independent risk factor for mortality was persistence of an eosinophil count below 0.0454·10(3)/uL (HR = 4.20; 95% CI 2.66-6.62). An NLCR value >7 was also an independent risk factor but was of lesser importance. The mean eosinophil count in survivors showed a tendency to increase rapidly and to achieve normal values between the second and third day. In these patients, the NLCR was <7 between the second and third day. CONCLUSION: Both sustained eosinopenia and persistence of an NLCR >7 were independent markers of mortality in patients with bacteremia.

Costes asociados a las bacteriemias nosocomiales en un hospital universitario / Costs associated with nosocomial bacteraemias in a University Hospital

Objetivo Describir el incremento de costes de los pacientes que presentaron algún episodio de bacteriemia nosocomial (BN) en un hospital universitario respecto al coste de los pacientes con la misma patología, que no la presentaron. Métodos Estudio descriptivo y retrospectivo. Población de estudio: todos los episodios de hospitalización entre enero de 2005 y diciembre de 2007. Se compararon los costes de los pacientes que presentaron algún episodio de BN, con los que no la presentaron. La variable dependiente fue el coste del episodio de hospitalización, la variable explicativa principal la presencia de BN. Se ajustó un modelo lineal generalizado con distribución gamma y función de link logaritmo, dada la distribución de los costes. Resultados Se analizaron 640 hospitalizaciones con BN y 28.459 sin. El impacto en costes de los pacientes con BN fue de 9.430.713€. El coste incremental medio de las hospitalizaciones con BN ajustado por patología fue de 14.735,5€. El foco más frecuente fue el catéter (35,5%), con un coste incremental medio de 18.078€. En el modelo multivariante el coste de los enfermos con BN con microorganismos gram (+) involucrados fue 2,1 veces superior al de los enfermos sin bacteriemia (IC 1,96-2,23), si el microorganismo era gram (-) fue 1,8 veces superior (IC 1,70-1,93), y si era un hongo fue 2,4 veces superior (IC 1,95-2,89). Conclusiones Este análisis evidencia un importante impacto económico producido por las BN y da una medida del coste oportunidad que supone invertir recursos para evitarlas. Conocer el foco causante de la bacteriemia permite priorizar grupos de pacientes en los que impulsar acciones encaminadas a esta prevención (AU)

Objective To describe the increase in costs due to patients who had any episode of nosocomial bacteraemia (NB) in a University Hospital, compared to the costs of patients with the same illness who did not. Methods Descriptive and retrospective study. Population: all hospitalisation episodes between January 2005 and December 2007. We compared the patients who suffered some episode of NB, with the patients who did not. Dependent variable: cost of the hospitalisation episode. Main explanatory variable: presence of nosocomial bacteraemia. A generalized linear model was adjusted, with Gamma distribution and link logarithm function, given the distribution of the costs. Results There were 640 hospital episodes with NB and 28,459 with no NB. The average incremental cost for the hospitalisations with NB was 14,735.5€, adjusted for the disease. The impact on the costs for the hospital due to patients with NB was 9,430,713€. The most frequent source of infection was the catheter (35.5%), with an average increase in cost of 18,078€. In the multivariable model, the cost of patients with NB and involving a Gram(+) microorganism was 2.1 times more than that of patients without bacteraemia (95% CI; 1.96-2.23), if the microorganism was Gram(-) it was 1.8 times more (95% CI; 1.70-1.93), and for a fungus it was 2.4 time more (95% CI; 1.95-2.89).Conclusions This analysis shows the significant impact in the financial costs due to NB, and gives a measure of the cost-benefit of investing in resources to prevent them. Knowing the source cause of the bacteraemia allows priority to be given to these areas and to promote the necessary actions designed to prevent them (AU)

[Costs associated with nosocomial bacteraemias in a University Hospital]. / Costes asociados a las bacteriemias nosocomiales en un hospital universitario.

OBJECTIVE: To describe the increase in costs due to patients who had any episode of nosocomial bacteraemia (NB) in a University Hospital, compared to the costs of patients with the same illness who did not. METHODS: Descriptive and retrospective study. POPULATION: all hospitalisation episodes between January 2005 and December 2007. We compared the patients who suffered some episode of NB, with the patients who did not. Dependent variable: cost of the hospitalisation episode. Main explanatory variable: presence of nosocomial bacteraemia. A generalized linear model was adjusted, with Gamma distribution and link logarithm function, given the distribution of the costs. RESULTS: There were 640 hospital episodes with NB and 28,459 with no NB. The average incremental cost for the hospitalisations with NB was 14,735.5€, adjusted for the disease. The impact on the costs for the hospital due to patients with NB was 9,430,713€. The most frequent source of infection was the catheter (35.5%), with an average increase in cost of 18,078€. In the multivariable model, the cost of patients with NB and involving a Gram(+) microorganism was 2.1 times more than that of patients without bacteraemia (95% CI; 1.96-2.23), if the microorganism was Gram(-) it was 1.8 times more (95% CI; 1.70-1.93), and for a fungus it was 2.4 time more (95% CI; 1.95-2.89). CONCLUSIONS: This analysis shows the significant impact in the financial costs due to NB, and gives a measure of the cost-benefit of investing in resources to prevent them. Knowing the source cause of the bacteraemia allows priority to be given to these areas and to promote the necessary actions designed to prevent them.

[Results of a multidisciplinary and multifocal project to reduce bacteraemia caused by central venous catheters in non critical patients in a university hospital]. / Resultados de un proyecto multidisciplinar y multifocal para la disminución de la bacteriemia causada por catéter venoso central, en pacientes no críticos, en un hospital universitario.

OBJECTIVE: To evaluate a multidisciplinary and multifocal intervention in order to reduce catheter related bloodstream infections (CRBI), based on previously identified risk factors in non-critical patients. METHODS: A pre-post-intervention study, 2004-2006. POPULATION: patients with a central venous catheter (CVC). The primary endpoint was the CRBI. Other studied variables were patient characteristics, insertion, maintenance and removal of the catheter. The intervention consisted of baseline knowledge and identifying risk factors. In a second period, there was specific training on these identified risk factors and communication of the results, monitoring and evaluation of the CVC inserted. RESULTS: We analysed 175 and 200 CVC, respectively. The incidence of CRBI was 15.4% during the pre-intervention and 4.0% in the post-intervention period (P<.001). The incidence of BRC by CVC days in the first group was 8.8 infections 1.000 days of CVC and the second 2,3 (P=.0009). The multivariate analysis found an increased risk of CRBI during the first period (OR 4.32; 95% CI: 1.81-10.29) and the use of total parenteral nutrition (OR: 2.37; 95% CI: 1.10-5. 12). CONCLUSION: The application of specific measures directed at all non-critical patients in the entire hospital and involving a large number of professionals has achieved a decrease incidence of 73.9% of CRBI. An acceptable incidence of CRBI was obtained, and, with the completion of the project together with a new awareness, the situation will continue to improve.

Resultados de un proyecto multidisciplinar y multifocal para la disminución de la bacteriemia causada por catéter venoso central, en pacientes no críticos, en un hospital universitario / Results of a multidisciplinary and multifocal project to reduce bacteraemia caused by central venous catheters in non critical patients in a university hospital

Objetivo Evaluar una intervención multidisciplinar y multifocal en pacientes no críticos, para la reducción de bacteriemias relacionadas con los catéteres venosos centrales (BRC), basada en la corrección de factores de riesgo de la propia institución. Métodos Estudio pre-postintervención, 2004-2006. Población de estudio: pacientes portadores de catéter venoso central (CVC), la variable principal fue la BRC; otras variables fueron datos del paciente, de inserción, mantenimiento y retirada del catéter. La intervención consistió en conocer la situación basal e identificar factores de riesgo, y en el segundo período mejoras en el protocolo de inserción y mantenimiento de CVC, formación específica sobre los factores de riesgo, difusión de resultados, seguimiento y evaluación de los CVC insertados. Resultados Se analizaron 175 y 200 CVC respectivamente. Se observó una incidencia de BRC de 15,4% durante el periodo preintervención y de 4,0% en el período post-intervención (p<0,001). La incidencia de BRC por días de CVC en el primer grupo fue de 8,8 infecciones por 1.000 días de CVC y en el segundo 2,3 (p=0,009). En el análisis multivariado se encontró aumento del riesgo de BRC en los CVC insertados durante el primer periodo (OR:4,32; IC 95%:1,81-10,29), y en el uso de nutrición parenteral total, (OR:2,37; IC 95%:1,10-5,12).Conclusión La aplicación de medidas específicas dirigidas a todo el hospital e implicando a un gran número de profesionales, ha conseguido una disminución del 73,9% de BCR, situando la bacteriemia en cifras aceptables y creando una “cultura” responsable de que, una vez terminado el proyecto, las tasas de BRC siguieran mejorando (AU)

Objective To evaluate a multidisciplinary and multifocal intervention in order to reduce catheter related bloodstream infections (CRBI), based on previously identified risk factors in non-critical patients. MethodsA pre-post-intervention study, 2004-2006. Population: patients with a central venous catheter (CVC). The primary endpoint was the CRBI. Other studied variables were patient characteristics, insertion, maintenance and removal of the catheter. The intervention consisted of baseline knowledge and identifing risk factors. In a second period, there was specific training on these identified risk factors and communication of the results, monitoring and evaluation of the CVC inserted. Results We analysed 175 and 200 CVC, respectively. The incidence of CRBI was 15.4% during the pre-intervention and 4.0% in the post-intervention period (P<.001). The incidence of BRC by CVC days in the first group was 8.8 infections 1.000 days of CVC and the second 2,3 (P=.0009). The multivariate analysis found an increased risk of CRBI during the first period (OR 4.32; 95% CI: 1.81-10.29) and the use of total parenteral nutrition (OR: 2.37; 95% CI: 1.10-5. 12).Conclusion The application of specific measures directed at all non-critical patients in the entire hospital and involving a large number of professionals has achieved a decrease incidence of 73.9% of CRBI. An acceptable incidence of CRBI was obtained, and, with the completion of the project together with a new awareness, the situation will continue to improve (AU)

Características clínicas diferenciales entre las bacteriemias por Enterococcus faecalis y Enterococcus faecium / Differentiating clinical characteristics in bacteriemia caused by Enterococcus faecalis or Enterococcus faecium

Introducción Los enterococos son causantes de infecciones graves, como endocarditis y bacteriemias. Durante las últimas décadas, las infecciones enterocócicas han ganado importancia debido al aumento del número de casos. El conocimiento de los factores predisponentes al aislamiento de Enterococcus faecalis o Enterococcus faecium puede ser útil para mejorar el tratamiento empírico de las bacteriemias. Métodos Estudio retrospectivo de los pacientes hospitalizados diagnosticados de bacteriemia enterocócica (enero 2000–diciembre 2006). Se analizaron datos demográficos, clínicos, microbiológicos, exposición antibiótica, tratamientos y pronóstico. Para identificar los factores predisponentes al aislamiento de E. faecalis o E. faecium se llevó a cabo un análisis comparativo univariado y después un análisis multivariado. Resultados Se estudiaron 228 episodios de bacteriemia: 168 de E. faecalis y 60 de E. faecium. Todos los aislamientos de E. faecalis fueron sensibles a ampicilina, aunque sólo el 25% lo fue en el grupo de E. faecium. Hubo un caso de resistencia a vancomicina. Las variables que se asociaron independientemente a la adquisición de bacteriemia por E. faecium cuando se compararon con las bacteriemias producidas por E. faecalis fueron el ingreso en una unidad quirúrgica (OR: 4,223; p=0,001), más de 5 días de tratamiento previo con cefalosporinas o carbapenémicos (OR: 2,564; p=0,013 y OR: 2,652; p=0,027, respectivamente), la administración previa de penicilinas (OR: 2,008; p=0,044), Simplified Acute Physiology Score superior a 30 al ingreso (OR: 3,530; p=0,001) y enfermedad hepática de base (OR: 3,754; p<0,001).Conclusiones Debido al diferente patrón de resistencia de ambas especies enterocócicas, es esencial el conocimiento de los factores predisponentes a la adquisición de bacteriemia por una u otra especie a fin de establecer un tratamiento empírico antibiótico adecuado (AU)

Introduction Enterococci are responsible for severe infections, such as endocarditis and bacteremia. During recent decades, enterococcal infections have grown in importance because of the increasing number of cases. Knowledge of the factors predisposing to acquisition of infection by E. faecalis or E. faecium may be useful to improve the empirical treatment. Methods Retrospective study of patients diagnosed with enterococcal bacteremia and hospitalized over a 7-year period (January 2000–December 2006), analyzing demographic data, clinical and microbiological characteristics, antibiotic exposure, treatment, and outcome. To identify the predisposing factors for isolation of E. faecalis or E. faecium in a clinical specimen, we performed univariate comparisons between the 2 groups, and subsequently, multivariate logistic regression analysis.ResultsA total of 228 episodes of bacteremia were recorded, 168 caused by E. faecalis and 60 by E. faecium. All E. faecalis isolates were susceptible to ampicillin, but only 25% of E. faecium were ampicillin-susceptible. There was only 1 vancomycin-resistant isolate. The variables independently associated with acquisition of E. faecium bacteriemia were surgical ward admission (odds ratio [OR], 4.223; P=.001), >5 days of previous treatment with cephalosporins (OR, 2.564; P=.013), >5 days of carbapenems (OR, 2.652; P=.027), previous administration of penicillins (OR, 2.008; P=0.044), SAPS score >30 at admission (OR, 3.530; P=0.001), and hepatobiliary disease as a comorbid condition (OR, 3.754; P<0.001), Conclusion Because of the differing susceptibility patterns of the enterococcal species studied, it is essential to know the factors predisposing to acquisition of infection by one or the other species to initiate adequate empirical treatment (AU)

[Differentiating clinical characteristics in bacteriemia caused by Enterococcus faecalis or Enterococcus faecium]. / Características clínicas diferenciales entre las bacteriemias por Enterococcus faecalis y Enterococcus faecium.

INTRODUCTION: Enterococci are responsible for severe infections, such as endocarditis and bacteremia. During recent decades, enterococcal infections have grown in importance because of the increasing number of cases. Knowledge of the factors predisposing to acquisition of infection by E. faecalis or E. faecium may be useful to improve the empirical treatment. METHODS: Retrospective study of patients diagnosed with enterococcal bacteremia and hospitalized over a 7-year period (January 2000-December 2006), analyzing demographic data, clinical and microbiological characteristics, antibiotic exposure, treatment, and outcome. To identify the predisposing factors for isolation of E. faecalis or E. faecium in a clinical specimen, we performed univariate comparisons between the 2 groups, and subsequently, multivariate logistic regression analysis. RESULTS: A total of 228 episodes of bacteremia were recorded, 168 caused by E. faecalis and 60 by E. faecium. All E. faecalis isolates were susceptible to ampicillin, but only 25% of E. faecium were ampicillin-susceptible. There was only 1 vancomycin-resistant isolate. The variables independently associated with acquisition of E. faecium bacteriemia were surgical ward admission (odds ratio [OR], 4.223; P=.001), >5 days of previous treatment with cephalosporins (OR, 2.564; P=.013), >5 days of carbapenems (OR, 2.652; P=.027), previous administration of penicillins (OR, 2.008; P=0.044), SAPS score >30 at admission (OR, 3.530; P=0.001), and hepatobiliary disease as a comorbid condition (OR, 3.754; P<0.001), CONCLUSION: Because of the differing susceptibility patterns of the enterococcal species studied, it is essential to know the factors predisposing to acquisition of infection by one or the other species to initiate adequate empirical treatment.

High prevalence of extended-spectrum beta-lactamase-producing enterobacteriaceae in bacteremia after transrectal ultrasound-guided prostate biopsy: a need for changing preventive protocol.

OBJECTIVES: To determine whether the incidence of bacteremia after transrectal ultrasound-guided prostate biopsy (TRUSGPB) significantly diminishes with the setting up of a new preventive protocol. This protocol was set up after detecting an augmented incidence of bacteremia after TRUSGPB with a high prevalence of antibiotic-resistant microorganisms. METHODS: Retrospective descriptive and prospective intervention study performed at a University Hospital. PARTICIPANTS: Patients undergoing TRUSGPB under the old preventive protocol (January 2006-February 2007), that is, amoxicillin-clavulanate 500 mg tid the day before, the day of the procedure, and 1 day after the procedure, and after setting up a new protocol (March 2007-April 2008), that is, 2 g cefoxitin 1 hour before the procedure and ciprofloxacin 750 mg p.o. bid the day before, the day of the procedure, and 3 days after the procedure; dipstick urinalysis was performed before the procedure, and patients with positive results were not biopsied. RESULTS: Incidence of bacteremia with old and new protocols: 9 of 204 procedures (4.4%) vs 2 of 207 (0.9%), (P = .03). Four isolates (44.4%) under the old protocol produced extended-spectrum beta-lactamase (ESBL). With the new protocol, 2 (0.9%) cases of non-ESBL Escherichia coli bacteremia were observed. Sixty-five (23.8%) cases were not biopsied because of positive result of dipstick urinalysis, lack of antibiotic prophylaxis adherence, or altered coagulation parameters. CONCLUSIONS: Antibiotic prophylaxis for TRUSGPB should take into account local resistance patterns. Cefoxitin could be used as prophylaxis in centers with high prevalence of ESBL enterobacteriaceae. Before TRUSGPB, excluding patients with positive results of dipstick urinalysis is an advisable practice.

Respuesta a Echarte et al / Reply Echarte et al

No disponible

Respuesta a Ortega et al / Reply Ortega et al

No disponible

Moisturizing body milk as a reservoir of Burkholderia cepacia: outbreak of nosocomial infection in a multidisciplinary intensive care unit.

BACKGROUND: An outbreak of severe nosocomial Burkholderia cepacia infections in patients admitted to intensive care unit (ICU), including investigation of the reservoir, is described. METHODS: Over a period of 18 days, isolates of Burkholderia cepacia were recovered from different biological samples from five patients who were admitted to a multidisciplinary 18-bed intensive care unit. Isolation of B. cepacia was associated with bacteraemia in three cases, lower respiratory tract infection in one and urinary tract infection in one. Contact isolation measures were instituted; new samples from the index patients and adjacent patients were collected; and samples of antiseptics, eau de Cologne and moisturizing body milk available in treatment carts at that time were collected and cultured. RESULTS: B. cepacia was isolated from three samples of the moisturizing body milk that had been applied to the patients. Three new hermetically closed units, from three different batches, were sent for culture; two of these were positive as well. All strains recovered from environmental and biological samples were identified as belonging to the same clone by pulsed-field gel electrophoresis. The cream was withdrawn from all hospitalization units and no new cases of B. cepacia infection developed. CONCLUSION: Moisturizing body milk is a potential source of infection. In severely ill patients, the presence of bacteria in cosmetic products, even within accepted limits, may lead to severe life-threatening infections.

[Community bacteremia ambulatory treated or identified after discharge from the emergency department]. / Bacteriemia comunitaria tratada o identificada de forma ambulatoria tras el alta de un servicio de urgencias.

BACKGROUND AND OBJECTIVE: The patients with bacteremia usually require hospital admission. In occasions they are remitted to their home, due to inappropriate diagnosis or rapid clinical improvement. The study describes the evolution and the interventions carried out in patients with community bacteremia that were remitted to their home. PATIENTS AND METHOD: Prospective observational study carried out in a university hospital, of 450 beds, from March of 2000 until December of 2003. The hospital has a team that daily evaluated all blood cultures practiced; the patients with bacteremia remitted to home from the Emergency Department with inappropriate antibiotic were identified. RESULTS: During the period of study 1,172 episodes of true bacteremia were diagnosed, of these 247 (21.1%) were remitted to their home. In 50 cases (20.2%) it was considered necessary to contact with the patient: 36 for inappropriate empiric antibiotic treatment, 12 without antibiotic treatment and 2 for lack of information. Antibiotic treatment was initiated or modified in 34 cases, and 10 required hospital admission. Excluding the 66 patients who died in the first 48 h, the crude mortality of the patients remitted to home was inferior (4%) to that of the patients that required hospital admission (11.9%). CONCLUSIONS: One fifth of community bacteremia were ambulatory treated, frequently the antibiotic treatment was inappropriate, it is necessary to guarantee an appropriate control of this population.

Bacteriemia comunitaria tratada o identificada de forma ambulatoria tras el alta de un servicio de urgencias / Community bacteremia ambulatory treated or identified after discharge from the emergency department

Fundamento y objetivo: Los pacientes con bacteriemia suelen requerir ingreso hospitalario, aunque en ocasiones se les remite a su domicilio por diagnóstico inapropiado o rápida mejoría. En el presente estudio se describen la evolución y las intervenciones realizadas en los pacientes con bacteriemia comunitaria remitidos a domicilio. Pacientes y método: Estudio prospectivo realizado en un hospital de 450 camas desde marzo de 2000 hasta diciembre de 2003. El centro dispone de un equipo que controla todas las bacteriemias. Se identificó a los pacientes enviados a su domicilio desde urgencias y que recibieron tratamiento antimicrobiano inapropiado. Resultados: Se diagnosticó a 1.172 pacientes con bacteriemia verdadera, de los que 247 (21,1%) fueron remitidos a su domicilio. En 50 casos (20,2%) se consideró necesario revaluar al paciente: 36 por tratamiento antibiótico inapropiado, 12 sin tratamiento antibiótico y 2 por falta de información. En 34 pacientes (64%) se instauró o modificó el tratamiento antimicrobiano y 10 (20%) requirieron ingreso hospitalario. Excluyendo a los 66 pacientes que fallecieron en las primeras 48 h, la mortalidad bruta de los pacientes remitidos a domicilio fue inferior (4%) a la de los pacientes ingresados (11,9%). Conclusiones: Una quinta parte de las bacteriemias comunitarias fueron tratadas de forma ambulatoria. Con frecuencia el tratamiento antibiótico fue inapropiado. Es necesario garantizar un control adecuado de estos pacientes

Background and objective: The patients with bacteremia usually require hospital admission. In occasions they are remitted to their home, due to inappropriate diagnosis or rapid clinical improvement. The study describes the evolution and the interventions carried out in patients with community bacteremia that were remitted to their home. Patients and method: Prospective observational study carried out in a university hospital, of 450 beds, from March of 2000 until December of 2003. The hospital has a team that daily evaluated all blood cultures practiced; the patients with bacteremia remitted to home from the Emergency Department with inappropriate antibiotic were identified. Results: During the period of study 1,172 episodes of true bacteremia were diagnosed, of these 247 (21.1%) were remitted to their home. In 50 cases (20.2%) it was considered necessary to contact with the patient: 36 for inappropriate empiric antibiotic treatment, 12 without antibiotic treatment and 2 for lack of information. Antibiotic treatment was initiated or modified in 34 cases, and 10 required hospital admission. Excluding the 66 patients who died in the first 48 h, the crude mortality of the patients remitted to home was inferior (4%) to that of the patients that required hospital admission (11.9%). Conclusions: One fifth of community bacteremia were ambulatory treated, frequently the antibiotic treatment was inappropriate, it is necessary to guarantee an appropriate control of this population