Update on the epidemiology of carbapenemases in Latin America and the Caribbean.

INTRODUCTION: Carbapenemases are ß-lactamases able to hydrolyze a wide range of ß-lactam antibiotics, including carbapenems. Carbapenemase production in Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter spp., with and without the co-expression of other ß-lactamases is a serious public health threat. Carbapenemases belong to three main classes according to the Ambler classification: class A, class B, and class D. AREAS COVERED: Carbapenemase-bearing pathogens are endemic in Latin America. In this review, we update the status of carbapenemases in Latin America and the Caribbean. EXPERT OPINION: Understanding the current epidemiology of carbapenemases in Latin America and the Caribbean is of critical importance to improve infection control policies limiting the dissemination of multi-drug-resistant pathogens and in implementing appropriate antimicrobial therapy.

[Evaluation of antimicrobial consumption en 15 Chilean hospitals: Results of a collaborative work, 2013]. / Evaluación del consumo de antimicrobianos en 15 hospitales chilenos: Resultados de un trabajo colaborativo, 2013.

Surveillance of antimicrobial consumption is a central part in programs of antibiotic stewardship. However, in Chile there are no national data on antibiotic consumption representing a significant number of hospitals by clinical services. In 2013 a survey was sent to multiple Chilean hospitals to evaluate antimicrobial consumption in medical services (MS), surgery services (SS) and critical care units (ICU). We used the standardized methodology recommended by the WHO, using the number of DDD/100 days beds. In the MS and SS beta-lactam and no beta-lactam antibiotics commonly used were evaluated. In the ICU consumption vancomycin, linezolid, imipenem, merope-nem, colistin and tigecycline was evaluated. Fifteen hospitals reported the density of antimicrobial consumption. Ceftriaxone and cloxacillin were the most commonly used antibiotics in general services (average cloxacillin 4,9 DDD/100 bed days in MS and 8,0 DDD/100 in SS; ceftriaxone 13,5 DDD/100 in MS and 16,7 DDD/100 in SS). In the SS there was also a significant consumption of metronidazole (average 14,5 DDD/100 bed days). In the ICU there was an important variability of consumption of selected antibiotics. This study reports the average and range of antibiotic consumption in MS, SS, and ICU from a significant number of hospitals in the country, during 2013. This information allows hospitals to compare their consumption of antibiotics with a significant sample of Chilean hospitals. Analysis of this information should consider a careful interpretation according to the sample shown here and the reality of each hospital.

Evaluación del consumo de antimicrobianos en 15 hospitales chilenos: Resultados de un trabajo colaborativo, 2013 / Evaluation of antimicrobial consumption en 15 Chilean hospitals: Results of a collaborative work, 2013

La vigilancia del consumo de antimicrobianos es parte central en los programas de utilización de antimicrobianos. Sin embargo, en Chile no se conocen datos del consumo de antibacterianos por servicios clínicos, que representen un número importante de hospitales. En el año 2013 se envió una encuesta a múltiples hospitales chilenos para evaluar el consumo de antimicrobianos en los servicios clínicos de Medicina (SM), Cirugía (SC) y Unidades de Pacientes Críticos (UPC). Para ello se usó la metodología estandarizada recomendada por la OMS de DDD/100 días camas. En los SM y SC se evaluaron antibacterianos β-lactámicos y no β-lactámicos de uso frecuente. En las UPC se evaluó el consumo de vancomicina, linezolid, imipenem, meropenem, colistín y tigeciclina. Se obtuvo resultados de 15 hospitales, los cuales informaron la densidad de consumo de antimicrobianos de los servicios mencionados. Ceftriaxona y cloxacilina fueron los antimicrobianos más utilizados en servicios generales (promedio cloxacilina 4,9 DDD/100 días cama en SM y 8,0 DDD/100 en SC; ceftriaxona 13,5 DDD/100 en SM y 16,7 DDD/100 en SC). En los SC se agrega además un consumo importante de metronidazol (promedio 14,5 DDD/100 días cama). En las UPC destaca la variabilidad de consumo de antimicrobianos seleccionados. Este estudio reporta el promedio y rangos de consumo de antibacterianos en SM, SC y UPC de un número importante de hospitales del país durante el año 2013. Esta información permite a los hospitales comparar su consumo de antibacterianos con una muestra significativa de hospitales chilenos. El análisis de esta información debe considerar una cuidadosa interpretación de acuerdo a la muestra aquí representada y la realidad de cada uno de los hospitales.

Surveillance of antimicrobial consumption is a central part in programs of antibiotic stewardship. However, in Chile there are no national data on antibiotic consumption representing a significant number of hospitals by clinical services. In 2013 a survey was sent to multiple Chilean hospitals to evaluate antimicrobial consumption in medical services (MS), surgery services (SS) and critical care units (ICU). We used the standardized methodology recommended by the WHO, using the number of DDD/100 days beds. In the MS and SS beta-lactam and no beta-lactam antibiotics commonly used were evaluated. In the ICU consumption vancomycin, linezolid, imipenem, merope-nem, colistin and tigecycline was evaluated. Fifteen hospitals reported the density of antimicrobial consumption. Ceftriaxone and cloxacillin were the most commonly used antibiotics in general services (average cloxacillin 4,9 DDD/100 bed days in MS and 8,0 DDD/100 in SS; ceftriaxone 13,5 DDD/100 in MS and 16,7 DDD/100 in SS). In the SS there was also a significant consumption of metronidazole (average 14,5 DDD/100 bed days). In the ICU there was an important variability of consumption of selected antibiotics. This study reports the average and range of antibiotic consumption in MS, SS, and ICU from a significant number of hospitals in the country, during 2013. This information allows hospitals to compare their consumption of antibiotics with a significant sample of Chilean hospitals. Analysis of this information should consider a careful interpretation according to the sample shown here and the reality of each hospital.

Gram-negative infections in adult intensive care units of latin america and the Caribbean.

This review summarizes recent epidemiology of Gram-negative infections in selected countries from Latin American and Caribbean adult intensive care units (ICUs). A systematic search of the biomedical literature (PubMed) was performed to identify articles published over the last decade. Where appropriate, data also were collected from the reference list of published articles, health departments of specific countries, and registries. Independent cohort data from all countries (Argentina, Brazil, Chile, Colombia, Cuba, Mexico, Trinidad and Tobago, and Venezuela) signified a high rate of ICU infections (prevalence: Argentina, 24%; Brazil, 57%). Gram-negative pathogens, predominantly Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli, accounted for >50% of ICU infections, which were often complicated by the presence of multidrug-resistant strains and clonal outbreaks. Empirical use of antimicrobial agents was identified as a strong risk factor for resistance development and excessive mortality. Infection control strategies utilizing hygiene measures and antimicrobial stewardship programs reduced the rate of device-associated infections. To mitigate the poor health outcomes associated with infections by multidrug-resistant Gram-negative bacteria, urgent focus must be placed on infection control strategies and local surveillance programs.

Análisis de los fenotipos y genotipos de resistencia a eritromicina y clindamicina en cepas de Streptococcus pyogenes aisladas en Chile en un período de 10 años / Resistance phenotypes and genotypes of Streptococcus pyogenes clinical isolates in Chile over a 10-year period

Background: Macrolide and lincosamide resistance in Streptococcus pyogenes is due to the acquisition of mef, ermB and ermA genes, which confer different resistance phenotypes, namely M, MLSBconstitutive and MLSBinducible respectively. The last report of resistance in Chile was done in the period 1990-1998, in which resistance to macrolides was 5.4 percent, with M phenotype as the predominant one. Aim: To characterize the evolution of erythromycin and clindamycin resistance and their associated genes in S. pyogenes strains isolated from patients with invasive and non-invasive infections in the period 1996 to 2005. Material and Methods: Resistance to erythromycin and clindamycin was determined in 1,282 clinical isolates using the disk diffusion test. Resistant isolates were analyzed by polymerase chain reaction (PCR) for the presence of the above mentioned resistance genes. Results: Global resistance to erythromycin and clindamycin was 3.5 and 0.7 percent respectively. Eighty percent of the resistant strains possessed the M. phenotype. Conclusions: Resistance levels of S. pyogenes have decreased in Chile in the last years. Most resistant strains have M phenotype in contrast to many countries in which the MLSB constitutive phenotype is the predominant one.

[Resistance phenotypes and genotypes of Streptococcus pyogenes clinical isolates in Chile over a 10-year period]. / Análisis de los fenotipos y genotipos de resistencia a eritromicina y clindamicina en cepas de Streptococcus pyogenes aisladas en Chile en un período de 10 años.

BACKGROUND: Macrolide and lincosamide resistance in Streptococcus pyogenes is due to the acquisition of mef, ermB and ermA genes, which confer different resistance phenotypes, namely M, MLSBconstitutive and MLSBinducible respectively. The last report of resistance in Chile was done in the period 1990-1998, in which resistance to macrolides was 5.4%, with M phenotype as the predominant one. AIM: To characterize the evolution of erythromycin and clindamycin resistance and their associated genes in S. pyogenes strains isolated from patients with invasive and non-invasive infections in the period 1996 to 2005. MATERIAL AND METHODS: Resistance to erythromycin and clindamycin was determined in 1,282 clinical isolates using the disk diffusion test. Resistant isolates were analyzed by polymerase chain reaction (PCR) for the presence of the above mentioned resistance genes. RESULTS: Global resistance to erythromycin and clindamycin was 3.5 and 0.7% respectively. Eighty percent of the resistant strains possessed the M. phenotype. CONCLUSIONS: Resistance levels of S. pyogenes have decreased in Chile in the last years. Most resistant strains have M phenotype in contrast to many countries in which the MLSB constitutive phenotype is the predominant one.

[Treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in Latin America]. / Tratamiento de las infecciones causadas por Staphylococcus aureus resistente a meticilina en América Latina.

The global spread of MRSA means it is now a pathogen of worldwide public health concern. Within Latin America, MRSA is highly prevalent, with the proportion of S. aureus isolates that are methicillin-resistant on the rise, yet resources for managing the infection are limited. While several guidelines exist for the treatment of MRSA infections, many are written for the North American or European setting and need adaptation for use in Latin America. In this article, we aim to emphasize the importance of appropriate treatment of MRSA in the healthcare and community settings of Latin America. We present a summary of the available guidelines and antibiotics, and discuss particular considerations for clinicians treating MRSA in Latin America.

Treatment of methicillin-resistant Staphylococcus aureus in Latin America.

The global spread of methicillin-resistant Staphylococcus aureus (MRSA) means it is now a pathogen of worldwide public health concern. Within Latin America, MRSA is highly prevalent, with the proportion of S. aureus isolates that are methicillin-resistant on the rise, yet resources for managing the infection are limited. While several guidelines exist for the treatment of MRSA infections, many are written for the North American or European setting and need adaptation for use in Latin America. In this article, we aim to emphasize the importance of appropriate treatment of MRSA in the healthcare and community settings of Latin America. We present a summary of the available guidelines and antibiotics, and discuss particular considerations for clinicians treating MRSA in Latin America.

Treatment of methicillin-resistant Staphylococcus aureus in Latin America

The global spread of methicillin-resistant Staphylococcus aureus (MRSA) means it is now a pathogen of worldwide public health concern. Within Latin America, MRSA is highly prevalent, with the proportion of S. aureus isolates that are methicillin-resistant on the rise, yet resources for managing the infection are limited. While several guidelines exist for the treatment of MRSA infections, many are written for the North American or European setting and need adaptation for use in Latin America. In this article, we aim to emphasize the importance of appropriate treatment of MRSA in the healthcare and community settings of Latin America. We present a summary of the available guidelines and antibiotics, and discuss particular considerations for clinicians treating MRSA in Latin America.

[Updated acute community-acquired pneumonia in adults: Guidelines for initial antimicrobial therapy based on local evidence from the South American Working Group (ConsenSur II)]. / Neumonía aguda adquirida en la comunidad en adultos: Actualización de los lineamientos para el tratamiento antimicrobiano inicial basado en la evidencia local del Grupo de Trabajo de Sudamérica (ConsenSur II).

Community-acquired pneumonia (CAP) in adults is probably one of the infections affecting ambulatory patients for which the highest diversity of guidelines has been written worldwide. Most of them agree in that antimicrobial therapy should be initially tailored according to either the severity of the infection or the presence of comorbidities and the etiologic pathogen. Nevertheless, a great variability may be noted among the different countries in the selection of the primary choice in the antimicrobial agents, even for the cases considered as at a low-risk class. This fact may be due to the many microbial causes of CAP and specialties involved, as well as the different health-care systems effecting on the availability or cost of antibiotics. However, many countries or regions adopt some of the guidelines or design their own recommendations regardless of the local data, probably because of the scarcity of such data. This is the reason why we have developed a guideline for the initial treatment of CAP by 2002 upon the basis of several local evidences in South América (ConsenSur I). However, several issues deserve to be currently rediscussed as follows: certain clinical scores other than the Physiological Severity índex (PSI) have become more popular in clinical practice (i.e. CURB-65, CRB-65); some pathogens have emerged in the región, such as community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) and Legionella spp; new evidences on the performance of the rapid test for the etiologic diagnosis in CAP have been reported (eg. urinary Legionella andpneumococcus antigens); new therapeutic considerations needs to be approached (i.e. dosage reformulation, duration of treatment, emergence of novel antibiotics and clinical impact of combined therapy). Like in the first versión of the ConsenSur (ConsenSur I), the various current guidelines have helped to organize and stratify the present proposal, ConsenSur II.

Neumonía aguda adquirida en la comunidad en adultos: actualización de los lineamientos para el tratamiento antimicrobiano inicial basado en la evidencia local del Grupo de Trabajo de Sudamérica (ConsenSur II) / Updated acute community-acquired pneumonia in adults: guidelines for initial antimicrobial therapy based on local evidence from the South American Working Group (ConsenSur II)

Community-acquired pneumonia (CAP) in adults is probably one of the infections affecting ambulatory patients for which the highest diversity of guidelines has been written worldwide. Most of them agree in that antimicrobial therapy should be initially tailored according to either the severity of the infection or the presence of comorbidities and the etiologic pathogen. Nevertheless, a great variability may be noted among the different countries in the selection of the primary choice in the antimicrobial agents, even for the cases considered as at a low-risk class. This fact may be due to the many microbial causes of CAP and specialties involved, as well as the different health-care systems effecting on the availability or cost of antibiotics. However, many countries or regions adopt some of the guidelines or design their own recommendations regardless of the local data, probably because of the scarcity of such data. This is the reason why we have developed a guideline for the initial treatment of CAP by 2002 upon the basis of several local evidences in South América (ConsenSur I). However, several issues deserve to be currently rediscussed as follows: certain clinical scores other than the Physiological Severity índex (PSI) have become more popular in clinical practice (i.e. CURB-65, CRB-65); some pathogens have emerged in the región, such as community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) and Legionella spp; new evidences on the performance of the rapid test for the etiologic diagnosis in CAP have been reported (eg. urinary Legionella andpneumococcus antigens); new therapeutic considerations needs to be approached (i.e. dosage reformulation, duration of treatment, emergence of novel antibiotics and clinical impact of combined therapy). Like in the first versión of the ConsenSur (ConsenSur I), the various current guidelines have helped to organize and stratify the present proposal, ConsenSur II.

La neumonía adquirida por adultos en la comunidad (NAC) es, probablemente, una de las infecciones que afecta a los pacientes ambulatorios para la cual se ha escrito la mayor diversidad de lineamientos en todo el mundo. La mayoría de ellos concuerdan en que el tratamiento antimicrobiano debe ser ajustado inicialmente de acuerdo con la gravedad de la infección o con la presencia de co-morbilidades y el patógeno etiológico. Aun así, se puede notar una gran variabilidad entre los diferentes países en la selección de la elección primaria de los agentes antimicrobianos, incluso en los casos considerados como de bajo riesgo. Este hecho puede deberse a las múltiples causas microbianas de la NAC y las especialidades médicas involucradas, como así también los diferentes sistemas de asistencia de salud que afectan la disponibilidad o el costo de los antimicrobianos. No obstante, muchos países o regiones adoptan alguno de los lineamientos o diseñan sus propias recomendaciones independientemente de los datos locales, probablemente debido a la escasez de dichos datos. Por esta razón desarrollamos lineamientos para el tratamiento inicial de la NAC hacia el año 2002, sobre la base de varias evidencias locales en Sudamérica (ConsenSur I). Sin embargo, varios temas merecen discutirse nuevamente como sigue: ciertos puntajes clínicos además del índice Fisiológico de Severidad (IFS) se hicieron más populares en la práctica clínica (por ej. CURB-65, CRB-65); emergieron algunos patógenos en la región, tal como Staphylococcus aureus resistente adquirido en la comunidad (SAMR-AC) y Legionella spp; se reportaron nuevas evidencias sobre el desempeño de la prueba rápida para el diagnóstico etiológico de NAC (por ejemplo, Legionella urinaria y antígenos de Streptococcus pneumoniae); deben abordarse nuevas consideraciones terapéuticas (por ej.: reformulación de la dosis, duración del tratamiento, emergencia de antimicrobianos nuevos e impacto clínico del tratamiento...

Evolution of methicillin-resistant Staphylococcus aureus clones in Latin America.

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) is a prominent nosocomial bacterial pathogen, associated with significant morbidity and mortality. The global incidence is increasing, and Latin America is no exception. This article reviews MRSA clonal distribution in Latin America and implications for clinical practice. DESIGN: A PubMed literature search (1966-2008) identified 32 articles that characterized MRSA clones in Latin America. RESULTS: Data from these articles show that since 1990, several epidemic MRSA clones have spread in Latin America. The multidrug-resistant Brazilian clone is widespread, especially in Brazil and Argentina, but more recently clones with susceptibility to a range of antibiotics have been detected in Brazil, whereas in Argentina, as in Chile, Colombia and Paraguay, the multidrug-resistant Cordobes/Chilean clone prevails. In Mexico, the New York/Japan clone is most frequent. Data were not available from every country and, despite the increasing prevalence of community MRSA infections, most were collected from tertiary care centers. CONCLUSIONS: A variety of epidemic MRSA clones are circulating in Latin America, some of which harbor genes that encode multidrug resistance or enhanced pathogenicity. Continued collection and reporting of epidemiological data is crucial for effective prevention and treatment.

Epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in Latin America.

Methicillin-resistant Staphylococcus aureus (MRSA) has become a serious threat to public health worldwide. Ongoing surveillance is essential to support infection control committees and clinicians in the prevention and treatment of infection. However, in Latin America, resources for monitoring the changing epidemiology of MRSA remain limited. In this article, we review the current situation of MRSA in Latin America in order to highlight the need for a more harmonised effort to improve its management. Literature in the PubMed and SciELO databases as well as the website of the Pan American Health Organization were searched for articles and information about the epidemiology of MRSA in Latin America. MRSA is already the leading cause of nosocomial infection in the Latin American region, and the number of reports of community-acquired MRSA infections is also rising. However, the extent of the problem is not fully understood, especially since data tend to come from large hospitals whereas much of the population is served by small community healthcare centres that do not have extensive facilities for performing microbiological surveillance. In conclusion, wider-reaching and co-ordinated programmes to provide regular MRSA surveillance reports are required across the Latin American region.

[Impact of regulatory measures in the trends of community consumption of antibiotics in Chile]. / Impacto de medidas regulatorias en la tendencia de consumo comunitario de antibióticos en Chile.

BACKGROUND: The indiscriminate use of antibiotics increases the appearance of bacterial resistance and forces the use of more expensive alternatives. The Chilean Ministry of Health is regulating the consumption of antibiotics since September 1999. These regulatory measures restricted the sale of antibiotics only when these were prescribed by an MD or an DS. AIM: To study the impact of these regulatory measures on antibiotics sales in pharmacies. MATERIAL AND METHODS: A retrospective analysis of antibiotics sales in pharmacies from 1996 to 2000. The information was obtained from the International Marketing System (IMS Health), an auditing system of pharmacy sales. The consumption unit used was the Defined Daily Dose per 1000 inhabitants/day (DDD). RESULTS: There was an important reduction in DDD, after the introduction of regulatory measures, for amoxicillin, ampicillin, erythromycin, trimethoprim/sulpha, chroramphenicol, cloxacillin and phenoxymethylpenicillin. There was also a important fall in sales, expressed in dollars. CONCLUSIONS: The regulatory measures of the Ministry of Health, had an immediate and great impact on antibiotics sales in Chile.

Eficacia de la asociación penicilina, cloramfenicol y gentamicina en infección grave a germen desconocido / Efficacy of the combination penicillin, chloramphenicol and gentamicin in severe infection by an unknown germ

Con el objeto de comparar la eficacia de la asociación PNS, CAF y Gm en terapia empírica de infecciones graves, se estudiaron 21 pacientes de UCI o UCIM de HVB de Valparaíso, a quienes al ingreso se aplicó dicha terapia. 76% eran nosocomiales. Del total infecciones 12 septicemias de diverso foco y 9 neumonias. El 55% tuvo cultivos positivos en diversas muestras registrándose escasa sensibilidad a la combinación empleada. La mortalidad fue 57% siendo mayor en nosocomiales (68%) en el 75% por causas directamente ligadas a infección. De los sobreviventes la mayoría debió cambiar AB (curación primaria solo 19%). Se discute utilidad de asociaciones antibióticos y de PNS, CAF y GM en particular estimándose poco recomendable como terapia empírica de infecciones nosocomiales graves