Aspergillus endocarditis in the recent years, report of cases of a multicentric national cohort and literature review.

OBJECTIVES: (1) To describe the incidence, clinical characteristics, treatment and outcome of Aspergillus Endocarditis (AE) in a nationwide multicentric cohort (GAMES). (2) To compare the AE cases of the GAMES cohort, with the AE cases reported in the literature since 2010. (3) To identify variables related to mortality. METHODS: We recruited 10 AE cases included in the GAMES cohort (January 2008-December 2018) and 51 cases from the literature published from January 2010 to July 2019. RESULTS: 4528 patients with infectious endocarditis (IE) were included in the GAMES cohort, of them 10 (0.2%) were AE. After comparing our 10 cases with the 51 of the literature, no differences were found. Analysing the 61 AE cases together, 55.7% were male, median age 45 years. Their main underlying conditions were as follows: prosthetic valve surgery (34.4%) and solid organ transplant (SOT) (19.7%). Mainly affecting mitral (36.1%) and aortic valve (29.5%). Main isolated species were as follows: Aspergillus fumigatus (47.5%) and Aspergillus flavus (24.6%). Embolisms occurred in 54%. Patients were treated with antifungals (90.2%), heart surgery (85.2%) or both (78.7%). Overall, 52.5% died. A greater mortality was observed in immunosuppressed patients (59.4% vs. 24.1%, OR = 4.09, 95%CI = 1.26-13.19, p = .02), and lower mortality was associated with undergoing cardiac surgery plus azole therapy (28.1% vs. 65.5%, OR = 0.22, 95%CI = 0.07-0.72, p = .01). CONCLUSIONS: AE accounts for 0.2% of all IE episodes of a national multicentric cohort, mainly affecting patients with previous valvular surgery or SOT recipients. Mortality remains high especially in immunosuppressed hosts and azole-based treatment combined with surgical resection are related to a better outcome.

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES).

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

Healthcare-associated pneumonia: a prospective study in Spain / Neumonía asociada a cuidados sanitarios: un estudio prospectivo en España

OBJECTIVE: The aim of the study was to describe the epidemiological characteristics and factors related to outcome in Streptococcus pneumoniae and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated pneumonia (HCAP). PATIENTS AND METHOD: A 3-year prospective observational epidemiological case study of HCAP was conducted in seven Spanish hospitals. Microbiological and patient characteristics and outcomes were collected and classified by causative pathogen into 4 categories: "S. pneumoniae", "MRSA", "Others" and "Unknown". Patients were followed up 30 days after discharge. RESULTS: A total of 258 (84.6%) patients were enrolled (170 were men [65.9%]). Mean age was 72.4 years ± 15 years (95% CI [70.54-74.25]). The etiology of pneumonia was identified in 73 cases (28.3%): S. pneumoniae in 35 patients (13.6%), MRSA in 8 (3.1%), and other microorganisms in 30 patients (11.6%). Significant differences in rates of chronic obstructive pulmonary disease (p < 0.05), previous antibiotic treatment (p< 0.05), other chronic respiratory diseases, inhaled corticosteroids (p < 0.01), and lymphoma (p < 0.05) were observed among the four groups. Patients with MRSA pneumonia had received more previous antibiotic treatment (87.5%). Thirty-three (12.8%) patients died during hospitalisation; death in 27 (81.2%) was related to pneumonia. CONCLUSIONS: The etiology of HCAP was identified in only one quarter of patients, with S. pneumoniae being the most prevalent microorganism. Patients with chronic respiratory diseases more frequently presented HCAP due to MRSA than to S. pneumoniae. Death at hospital discharge was related in most cases to pneumonia

OBJETIVO: Describir las características epidemiológicas y factores relacionados con la neumonía asociada a cuidados sanitarios (NACS) causada por Streptococcus pneumoniae y Staphylococcus aureus resistente a meticilina (SARM). PACIENTES Y MÉTODOS: Estudio epidemiológico observacional prospectivo de casos a 3 años en siete hospitales españoles. Se recogieron las características microbiológicas y de los pacientes y sus resultados y se clasificaron en función del patógeno causante en 4 categorías: "S. pneumoniae", "SARM", "Otros" y "Desconocido". Al alta, se realizó un seguimiento de 30 días. RESULTADOS: Se incluyeron 258 (84,6%) pacientes (170 hombres [65.9%]; edad media 72,4 años ± 15 años (95% IC [70,54-74,25]). La etiología de la neumonía se identificó en 73 casos (28,3%): S. pneumoniae en 35 pacientes (13,6%), SARM en 8 (3,1%) y otros microorganismos en 30 pacientes (11,6%). Hubo diferencias significativas en tasas de enfermedad pulmonar obstructiva crónica (p < 0,05), tratamiento antibiótico previo (p < 0,05), otras enfermedades respiratorias crónicas, corticoides inhalados (p < 0,01) y linfoma (p < 0,05) entre los cuatro grupos. Los pacientes con NACS causada por SARM recibieron tratamiento antibiótico previo en mayor medida (87,5%). Treinta y tres (12,8%) pacientes murieron durante la hospitalización; en 27 (81,2%) debido a la neumonía. CONCLUSIONES: Se identificó la etiología de la NACS en solo un cuarto de los pacientes, siendo S. pneumoniae el patógeno más frecuente. En los pacientes con enfermedades respiratorias crónicas fue más frecuente la NACS causada por SARM. La muerte tras el alta hospitalaria se relacionó con la neumonía en la mayoría de los casos

Four weeks versus six weeks of ampicillin plus ceftriaxone in Enterococcus faecalis native valve endocarditis: A prospective cohort study.

Enterococcus faecalis infective endocarditis (EFIE) is a severe disease of increasing incidence. The objective was to analyze whether the outcome of patients with native valve EFIE (NVEFIE) treated with a short course of ampicillin plus ceftriaxone (4wAC) was similar to patients treated according to international guidelines (6wAC). Between January 2008 and June 2018, 1,978 consecutive patients with definite native valve IE were prospectively included in a national registry. Outcomes of patients with NVEFIE treated with 4wAC were compared to those of patients who received 6wAC. Three hundred and twenty-two patients (16.3%) had NVEFIE. One hundred and eighty-three (56.8%) received AC. Thirty-nine patients (21.3%) were treated with 4wAC for four weeks and 70 patients (38.3%) with 6wAC. There were no differences in age or comorbidity. Patients treated 6wAC presented a longer duration of symptoms before diagnosis (21 days, IQR 7-60 days vs. 7 days, IQR 1-22 days; p = 0.002). Six patients presented perivalvular abscess and all of these received 6wAC. Surgery was performed on 14 patients (35.9%) 4wAC and 34 patients (48.6%) 6wAC (p = 0.201). In-hospital mortality, one-year mortality and relapses among 4wAC and 6wAC patients were 10.3% vs. 11.4% (p = 0.851); 17.9% vs. 21.4% (p = 0.682) and 5.1% vs. 4.3% (p = 0.833), respectively. In conclusion, a four-week course of AC may be considered as an alternative regimen in NVEFIE, notably in patients with shorter duration of symptoms and those without perivalvular abscess. These results support the performance of a randomized clinical trial to evaluate the efficacy of this short regimen.

Antibiotic selection in the treatment of acute invasive infections by Pseudomonas aeruginosa: Guidelines by the Spanish Society of Chemotherapy / Elección del tratamiento antibiótico en la infección invasiva aguda por Pseudomonas aeruginosa: Guía de la Sociedad Española de Quimioterapia

Pseudomonas aeruginosa is characterized by a notable intrinsic resistance to antibiotics, mainly mediated by the expression of inducible chromosomic β-lactamases and the production of constitutive or inducible efflux pumps. Apart from this intrinsic resistance, P. aeruginosa possess an extraordinary ability to develop resistance to nearly all available antimicrobials through selection of mutations. The progressive increase in resistance rates in P. aeruginosa has led to the emergence of strains which, based on their degree of resistance to common antibiotics, have been defined as multidrug resistant, extended-resistant and panresistant strains. These strains are increasingly disseminated worldwide, progressively complicating the treatment of P. aeruginosa infections. In this scenario, the objective of the present guidelines was to review and update published evidence for the treatment of patients with acute, invasive and severe infections caused by P. aeruginosa. To this end, mechanisms of intrinsic resistance, factors favoring development of resistance during antibiotic exposure, prevalence of resistance in Spain, classical and recently appeared new antibiotics active against P. aeruginosa, pharmacodynamic principles predicting efficacy, clinical experience with monotherapy and combination therapy, and principles for antibiotic treatment were reviewed to elaborate recommendations by the panel of experts for empirical and directed treatment of P. aeruginosa invasive infections (AU)

Pseudomonas aeruginosa se caracteriza por una notable resistencia intrínseca a los antibióticos mediada fundamentalmente por la expresión de β-lactamasas cromosómicas inducibles y la producción constitutiva o inducible de bombas de expulsión. Además de esta resistencia intrínseca, P. aeruginosa posee una extraordinaria capacidad para desarrollar resistencia a prácticamente todos los antimicrobianos disponibles a través de la selección de mutaciones. El aumento progresivo de la resistencia en P. aeruginosa ha llevado a la aparición de cepas que, de acuerdo con el grado de resistencia frente a los antibióticos habituales, se han definido como multirresistentes, extensamente resistentes y panresistentes. Estas cepas se están diseminando mundialmente, complicando progresivamente el tratamiento de las infecciones por P. aeruginosa. En este escenario, el objetivo de las presentes recomendaciones es la revisión y puesta al día de la evidencia publicada para el tratamiento de pacientes con infección aguda, invasiva y grave por P. aeruginosa. Con este fin, se han revisado los mecanismos de resistencia intrínseca, factores que favorecen el desarrollo de resistencia durante la exposición a antibióticos, prevalencia de la resistencia en España, antibióticos clásicos así como los de reciente introducción activos frente a P. aeruginosa, principios farmacodinámicos predictores de eficacia, experiencia clínica con tratamientos en monoterapia o terapia combinada y principios del tratamiento antibiótico para elaborar por un panel de xpertos recomendaciones para el tratamiento empírico o dirigido de infecciones invasivas por P. aeruginosa (AU)

Microbiology in burns patients with blood stream infections: trends over time and during the course of hospitalization.

BACKGROUND: Bloodstream infections (BSI) are a major cause of mortality in burns patients. Knowledge of the microbiology is crucial to direct empirical therapy. We sought to determine the causative microorganisms and antibiotic resistance in burns patients with BSI. METHODS: All consecutive BSI episodes in a tertiary hospital burns unit from 2000 to 2014 were included. The following three subperiods were compared: 2000-2004, 2005-2009 and 2010-2014. Changes in BSI occurring during early and late hospitalization periods were evaluated. RESULTS: A total of 103 BSI episodes were included. The cumulative incidence was 2.4 episodes/1000 patient days. A positive trend in the frequency of Gram-negative BSI, especially in the upsurge of Pseudomonas aeruginosa and Klebsiella spp. BSI after 2004, was observed. The most common causative pathogens in early BSI were Gram-positive microorganisms. P. aeruginosa and Klebsiella spp. became the predominant aetiology in the fourth week of hospitalization and beyond. There was a progressive increase in imipenem-resistant P. aeruginosa over time (0%, 67%, 75% in 2000-2004, 2005-2009, 2010-2014, respectively) and during the hospital stay (50% vs. 85.7%, in <7 days-BSI vs. >30 days-BSI, respectively). A higher SOFA (Sepsis-related Organ Failure Assessment) score was associated with Gram-negative BSI versus non-Gram-negative BSI (median: 2.5 vs. 0; p = 0.041). CONCLUSIONS: There is a changing trend in the types of pathogens causing BSI in burns patients over the 14-year period and during the course of hospitalization. The problematic increase in carbapenem-resistance highlights the need for new antimicrobial stewardship policies and antibiotic prescribing protocols.

The use of ertapenem for the treatment of community-acquired pneumonia in routine hospital practice: a matched cohort study / Uso de ertapenem en la neumonía adquirida en la comunidad en la práctica clínica diaria: estudio de cohortes pareadas

Background. The clinical response to ertapenem in community-acquired pneumonia (CAP) at the setting of routine hospital practice has been scarcely evaluated. Methods. We retrospectively compared CAP cases treated with ertapenem or with other standard antimicrobials (controls) at a tertiary 1,434-bed center from 2005 to 2014. Results. Out of 6,145 patients hospitalized with CAP, 64 (1%) ertapenem-treated and 128 controls were studied (PSI IV-V 72%, mean age 73 years.). A significant higher proportion of bedridden patients (41% vs. 21%), residence in nursing homes (19% vs. 7%), previous use of antibiotics (39% vs. 29%) and necrotizing (13% vs. 1%) or complicated (36% vs. 19%) pneumonia, was observed in the ertapenem vs. non-ertapenem patients. Initial treatment with ertapenem was independently associated with an earlier resolution of signs of infection. In patients aged 65 or older the independent risks factors for mortality were: PSI score (7.0, 95%CI 1.8-27.7), bedridden status (4.6, 95%CI 1.1-20.9) and Health Care Associated Pneumonia (HCAP) (4.6, 95%CI 1.3-16.5). First-line treatment with ertapenem was an independent protector factor in this subgroup of patients (0.1, 95%CI 0.1-0.7). Conclusions. Ertapenem showed a superior clinical response in frail elderly patients with complicated community- acquired pneumonia, and it may be considered as a firstline therapeutic regimen in this setting (AU)

Introducción. La respuesta clínica a ertapenem en la neumonía adquirida en la comunidad (NAC) en el contexto de la práctica clínica diaria ha sido evaluada de forma insuficiente. Material y Métodos. Estudio retrospectivo, comparativo de pacientes con NAC tratados con ertapenem o con otros antimicrobianos en un hospital terciario de 1.434 camas en el período 2005-2014. Resultados. De los 6.145 pacientes hospitalizados con NAC, 64 (1%) tratados con ertapenem y 128 controles fueron incluidos en el estudio (PSI IV-V 72%, edad media 73 años). Se observó una proporción significativamente mayor de pacientes encamados (41% vs. 21%), institucionalizados (19% vs. 7%), con antibioterapia previa (39% vs. 29%) y con neumonías necrotizantes (13% vs. 1%) o complicadas (36% vs. 19%) en el grupo de ertapenem vs. no-ertapenem. El tratamiento inicial con ertapenem se asoció de forma independiente con una resolución más temprana de los signos de infección. En el subgrupo de pacientes con 65 años o más, los factores independientes de riesgo de mortalidad fueron: PSI score (7,0 IC95% 1,8-27,7), encamamiento (4,6 IC95% 1,1-20,9) y la Neumonía Asociada a Cuidados Sanitarios (NACS) (4,6 IC95% 1,3-16,5). El tratamiento en primera línea con ertapenem fue un factor protector independiente en este grupo de pacientes (0,1 IC95% 0,1-0,7). Conclusiones. El tratamiento con ertapenem se asoció a una respuesta clínica superior en el paciente anciano frágil con NAC complicada y se podría considerar como un régimen terapéutico de primera línea en este contexto (AU)

2016 Expert consensus document on prevention, diagnosis and treatment of short-term peripheral venous catheter-related infections in adult / Documento de Consenso sobre la prevención, diagnóstico y tratamiento de las infecciones por catéter venoso periférico en adultos

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 (AU)

El uso de catéteres vasculares es una práctica muy utilizada en los hospitales. El uso de catéteres venosos periféricos de corta duración se ha asociado con un elevado riesgo de bacteriemia nosocomial, lo que comporta una no despreciable morbilidad y mortalidad. La etiología de estas infecciones suele ser frecuentemente por Staphylococcus aureus, lo que explica su gravedad. En este documento de consenso, elaborado por un panel de expertos de La Sociedad Española de Infecciones Cardiovasculares con la colaboración de expertos de la Sociedad Española de Medicina Interna, La Sociedad Española de Quimioterapia y la Sociedad Española de Cirugía Torácica y Cardiovascular, pretende establecer unes normes para un mejor uso de los catéteres venosos periféricos de corta duración. El Documento revisa las indicaciones para su inserción, mantenimiento, registro, diagnóstico y tratamiento de las infecciones derivadas y las indicaciones para su retirada; haciendo énfasis en la formación continuada del personal sanitario para lograr una mayor calidad asistencial. Seguir las recomendaciones del consenso permitirá utilizar de una manera más homogénea los catéteres venosos periféricos minimizando el riesgo de infección y sus complicaciones (AU)

Infective endocarditis in hypertrophic cardiomyopathy: A multicenter, prospective, cohort study.

Infective endocarditis (IE) complicating hypertrophic cardiomyopathy (HCM) is a poorly known entity. Although current guidelines do not recommend IE antibiotic prophylaxis (IEAP) in HCM, controversy remains.This study sought to describe the clinical course of a large series of IE HCM and to compare IE in HCM patients with IE patients with and without an indication for IEAP.Data from the GAMES IE registry involving 27 Spanish hospitals were analyzed. From January 2008 to December 2013, 2000 consecutive IE patients were prospectively included in the registry. Eleven IE HCM additional cases from before 2008 were also studied. Clinical, microbiological, and echocardiographic characteristics were analyzed in IE HCM patients (n = 34) and in IE HCM reported in literature (n = 84). Patients with nondevice IE (n = 1807) were classified into 3 groups: group 1, HCM with native-valve IE (n = 26); group 2, patients with IEAP indication (n = 696); group 3, patients with no IEAP indication (n = 1085). IE episode and 1-year follow-up data were gathered.One-year mortality in IE HCM was 42% in our study and 22% in the literature. IE was more frequent, although not exclusive, in obstructive HCM (59% and 74%, respectively). Group 1 exhibited more IE predisposing factors than groups 2 and 3 (62% vs 40% vs 50%, P < 0.01), and more previous dental procedures (23% vs 6% vs 8%, P < 0.01). Furthermore, Group 1 experienced a higher incidence of Streptococcus infections than Group 2 (39% vs 22%, P < 0.01) and similar to Group 3 (39% vs 30%, P = 0.34). Overall mortality was similar among groups (42% vs 36% vs 35%, P = 0.64).IE occurs in HCM patients with and without obstruction. Mortality of IE HCM is high but similar to patients with and without IEAP indication. Predisposing factors, previous dental procedures, and streptococcal infection are higher in IE HCM, suggesting that HCM patients could benefit from IEAP.

Endocarditis in patients with ascending aortic prosthetic graft: a case series from a national multicentre registry.

OBJECTIVES: Endocarditis in patients with ascending aortic prosthetic graft (AAPG) is a life-threatening complication. The purpose of this study was to examine the clinical presentation and prognosis of patients with AAPG endocarditis included in a large prospective infectious endocarditis multicentre study. METHODS: From January 2008 to April 2015, 3200 consecutive patients with infectious endocarditis according to the modified Duke criteria, were prospectively included in the 'Spanish Collaboration on Endocarditis Registry (GAMES)' registry. Twenty-seven definite episodes of endocarditis (0.8%) occurred in patients with AAPG. RESULTS: During the study period, 27 cases of endocarditis were detected in patients with AAPG. The median age of patients was 61 years [interquartile range (IQR) 51-68 years] and 23 (85.2%) patients were male. The median time from AAPG surgery to the episode of AAPG infection was 24 months (IQR 6-108 months). The most frequently isolated micro-organisms were coagulase-negative staphylococci and S. aureus (11 patients, 40.7%). Four patients (14.8%) underwent medical treatment, whereas surgery was performed in 21 (77.7%). Two patients (7.4%) died before surgery could be performed. The median hospital stay prior to surgery was 7 days (IQR 4-21 days). Surgery consisted of replacing previous grafts with a composite aortic graft (10 cases) or aortic homograft (2 patients), and removal of a large vegetation attached to the valve of a composite tube (1 case). Nine patients had an infected aortic valve prosthesis without evidence of involvement of the AAPG. Isolated redo-aortic valve replacement was performed in 8 (88.9%) of these patients. Reinfection occurring during 1 year of follow-up was not detected in any patient. Two patients (7.4%) died while awaiting surgery and 6 did so after surgery (22.2%). A New York Heart Association (NYHA) Class IV was associated with mortality in patients undergoing surgery (P < 0.019). CONCLUSIONS: Most cases of endocarditis in patients with AAPG occur late after initial surgery. Mortality rate of patients with AAPG endocarditis who undergo surgery is acceptable. NYHA Class IV before surgery is associated with an increased postoperative mortality.

Predicting mortality in burn patients with bacteraemia.

OBJECTIVE: To determine factors associated with mortality in burn patients with bacteraemia. BACKGROUND: Previous studies have shown the negative impact of bacteraemia on the prognosis of burn patients, but only a few of these have analysed variables intervening in the clinical progress of these patients. METHODS: A retrospective study of adult burn patients (n = 73) with bacteraemia (103 episodes) in a Burns Unit during the 2000-2013 period. The study collected demographic variables, and comorbidity, injury-related and clinical data related to bacteraemia. Variables related to hospital mortality were analysed using a multiple logistic regression model. RESULTS: The cumulative incidence of bacteraemia was 4.4 episodes/100 patients. The mean age was 53.3 ± 19.2 years (65.8 % male). The median total body surface area (TBSA) was 35 %, while 50.7 % of the population had inhalation syndrome. The mean SOFA score at the onset of bacteraemia was 2.7 ± 3.8. The most common pathogen was Pseudomonas aeruginosa (17.5 %). The mortality rate was 24.7 %. The variables that were significantly associated with mortality were age (OR = 1.13), TBSA (OR = 1.05), SOFA score at the onset of bacteraemia (OR = 1.53) and recurrent bacteraemia (OR = 41.6). CONCLUSION: In addition to conventional risk factors, recurrence and organ dysfunction at the onset of bacteraemia are also associated with mortality, while the pathogen involved is not a prognostic factor.

Impact of ertapenem use on Pseudomonas aeruginosa and Acinetobacter baumannii imipenem susceptibility rates: collateral damage or positive effect on hospital ecology?

BACKGROUND: Conflicting evidence has been reported on the impact of ertapenem use on the susceptibility of Pseudomonas spp. to group 2 carbapenems. No extensive data for Acinetobacter baumannii are currently available. METHODS: A retrospective time-series segmented regression analysis was conducted in a tertiary centre from January 2001 to December 2011. Ertapenem was introduced in January 2005. Antimicrobial drug use was defined as the number of defined daily doses/100 patient-days (DDDs/100 PDs). Susceptibility (CLSI) was measured in terms of proportion and incidence density. RESULTS: Mean monthly use of imipenem was 2.9 ±â€Š0.9 DDDs/100 PDs, as compared with 1.2 ±â€Š0.7 DDDs/100 PDs for meropenem and 1.0 ±â€Š0.7 DDDs/100 PDs for ertapenem (after its introduction). After ertapenem adoption, a downward trend was seen in the use of imipenem (P = 0.016) and ciprofloxacin (P = 0.004). A total of 6272 Pseudomonas aeruginosa and 1093 A. baumannii isolates were evaluated. Susceptibility of P. aeruginosa to imipenem improved after ertapenem introduction, both according to the proportion of susceptible isolates (P = 0.002) and to the incidence density of resistance (P ≤ 0.001). No significant change was seen in A. baumannii susceptibility to imipenem (P = 0.772). By multiple linear regression analysis, the incidence density of imipenem-resistant P. aeruginosa increased with the use of imipenem (P = 0.003) and ciprofloxacin (P = 0.008). Occurrence of outbreaks (P ≤ 0.001) and use of gentamicin (P = 0.007) were associated with A. baumannii resistance to imipenem. CONCLUSIONS: Use of ertapenem was directly associated with a downward trend in the use of imipenem and ciprofloxacin, which may have contributed to improve the susceptibility of P. aeruginosa to imipenem. Ertapenem use had no impact on the susceptibility of A. baumannii to imipenem.

Influence of prior pneumococcal and influenza vaccination on outcomes of older adults with community-acquired pneumonia.

OBJECTIVES: To determine whether prior pneumococcal and seasonal influenza vaccination improves outcomes in older adults hospitalized for community-acquired pneumonia (CAP). DESIGN: Prospective, observational, multicenter study. SETTING: Five public hospitals providing universal free care to the whole population in three Spanish regions. PARTICIPANTS: Individuals aged 65 and older admitted to the hospital with CAP through the emergency department. MEASUREMENTS: Pneumococcal and influenza vaccination status. The primary study outcomes were intensive care unit (ICU) admission, length of hospital stay (LOS), and overall case-fatality rate. Outcome variables of individuals vaccinated with both vaccines were compared with outcomes of those who were unvaccinated. RESULTS: Two hundred thirty-eight individuals had received 23-valent pneumococcal polysaccharide vaccine and seasonal influenza vaccination and were compared with 195 unvaccinated individuals. No differences were found with respect to combined antibiotic therapy between groups (38.0% vs 39.7%; P = .80). Similar percentages of vaccinated and unvaccinated individuals required ICU admission (7.2% vs 8.2%; P = .69). Mean LOS was significantly shorter in vaccinated individuals (9.9 vs 12.4 days; P = .04). Overall case-fatality rates were similar in both groups (5.9% vs 5.1%; P = .73). After adjustment, LOS, risk of ICU admission, and overall case-fatality rate were not associated with prior pneumococcal and seasonal influenza vaccination. CONCLUSION: The clinical outcomes of vaccinated older adults hospitalized with CAP were not better than those observed in unvaccinated individuals.

Clinical experience with linezolid for the treatment of neurosurgical infections

Introducción: Evaluar el uso clínico de linezolid en el tratamiento de las infecciones neuroquirúrgicas. Métodos: Estudio retrospectivo observacional de una cohorte de pacientes hospitalizados que recibieron linezolid para tratamiento de infecciones neuroquirúrgicas con cultivo positivo, desde Julio de 2004 a febrero de 2009 en un hospital terciario español. Resultados: En el estudio se incluyeron 17 pacientes. Las principales comorbilidades fueron una o más de las siguientes: hemorragia subaracnoidea o intraventricular (n= 8), tumor sólido neurológico (n= 7), corticoides (n= 9) e hidrocefalia ( n= 6). Ocho pacientes fueron sometidos a craneotomía y 14 tenían un drenaje ventricular externo (EVD) como factor predisponente de infección. La meningitis fue la infección más común (11; 64,7%), seguida de ventriculitis (4; 23,5%) y absceso cerebral (2; 11,8%). El principal agente causal fue Staphylococcus spp coagulasa negativa (13; 76,5%). Linezolid fue usado como tratamiento incicial en 8 episodios, tras fracaso en 6 y por otras razones en 3. La vía oral fue usada en 9 (52,9%) episodios, de forma inicial en 2 casos. La duración media del tratamiento fue de 26,5 días (rango 15-58). No se observaron efectos adversos. Dieciseís pacientes (94,1%) fueron considerados curados. Hubo una recurrencia. La estancia media en el hospital fue de 45,6 (rango 15-112) días y la duración media del seguimiento fue de 7,2 (rango 0,4-32) meses. No hubo muertes relacionadas con los episodios activos. Coclusiones: Linezolid fue principalmente indicado en las infecciones postquirúrgicas asociadas a EVD por Staphylococcus spp coagulasa negativa. Fue inicialmente usado en la mayoría de los casos. Una alta tasa de curación clínica fue observada y no se detectaron efectos adversos. Más de la mitad de los pacientes se beneficiaron de las ventajas de la vía oral(AU)

Objectives: We sought to evaluate the clinical use of linezolid for the treatment of neurosurgical infections. Methods: Retrospective observational study of a cohort of hospitalized patients who received linezolid for a culture-positive neurosurgical infection from July 2004 to February 2009 in a tertiary hospital in Spain. Results: Seventeen patients were included in the study. Main comorbidities among these patients included one or more of the following: subarachnoidal or intraventricular hemorrhage (n=8), solid neurological cancer (n=7), corticosteroids (n=9) and hydrocephalus (n=6). Eight patients underwent a craniotomy and fourteen patients had an external ventricular drainage (EVD) as predisposing factors for infection. Meningitis was the most common infection (11; 64.7%), followed by ventriculitis (4; 23.5%) and brain abscesses (2; 11.8%). The main causative organisms were coagulase-negative Staphylococcus spp. (13; 76.5%). Linezolid was used as the initial therapy in 8 episodes, after therapy failure in 6 and for other reasons in 3. The oral route was used in 9 (52.9%) episodes; linezolid was initiated orally in 2 cases. The mean duration of treatment was 26.5 days (range 15-58). No adverse events were reported. Sixteen (94.1%) patients were considered cured. There was one recurrence. The mean length of hospital stay was 45.6 (range 15-112) days and the mean duration of follow- up was 7.2 (range 0.4-32) months. No related deaths occurred during active episodes. Conclusions: Linezolid was mainly indicated in post-neurosurgical EVD-associated infections due to coagulase-negative Staphylococcus spp. It was used as initial therapy in most cases. A high rate of clinical cure was observed and no related adverse events were reported. More than half of the patients were benefited by the advantages of the oral route of administration(AU)

Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study.

BACKGROUND: The associations between socioeconomic status and community-acquired pneumonia outcomes in adults have been studied although studies did not always document a relationship.The aim of this multicenter observational study was to determine the association between socioeconomic status and community-acquired pneumonia outcomes in the elderly, in the context of a public health system providing universal free care to the whole population. METHODS: A total of 651 patients aged > or =65 years hospitalized due to community-acquired pneumonia through the emergency departments of five Spanish public hospitals were recruited and followed up between May 2005 and January 2007. The primary outcomes studied were: length of stay, intensive care unit admission, overall mortality and readmission. Socioeconomic status was measured using both individual and community data: occupation [categorized in six social groups (I, II, III, IVa, IVb and V)], educational level (< or = primary level or > or = secondary level) and disposable family income of the municipality or district of residence [>12,500 euro (high municipality family income) and < or =12,500 euro (low municipality family income)]. The six social groups were further categorized as upper/middle social class (groups I-IVb) and lower class (group V).Bivariate and multivariate analyses were performed. OR and their 95% confidence intervals were calculated. All statistical tests were two tailed and statistical significance was established as p < 0.05. RESULTS: 17.7% of patients lived in a municipality or district with a high municipality family income and 63.6% were upper/middle social class (I-IVb). Only 15.7% of patients had a secondary education. The adjusted analysis showed no association between pneumonia outcomes and social class, educational level or municipality family income. However, length of stay increased significantly in patients in whom the factors, living alone and being a smoker or ex-smoker coincided (p < 0.001). CONCLUSIONS: We measured socioeconomic status using both individual and community data and found no association between social class, educational level or municipality family income and the variables of pneumonia outcomes. The lack of differences between social classes supports the provision of universal, equitable health care by the public health system.

Validity of self-reported pneumococcal vaccination status in the elderly in Spain.

The objective of this study was to evaluate the validity of information reported by the elderly on 23-valent pneumococcal polysaccharide vaccine (23vPPV) vaccination status. A cross-sectional, observational study was carried out in patients aged >or=65 years admitted to five Spanish hospitals. Data on 23vPPV vaccination history were obtained through interview of the patient or close relative and review of written medical information. The validity of the patient self-report was compared to the written medical information by calculation of the sensitivity, specificity, concordance, positive predictive value (PPV) and negative predictive value (NPV). A total of 2484 patients were initially included of whom 1814 patients (73%) responded about their vaccination status. The global sensitivity of the patient self-report was 0.74 and the specificity 0.95. The PPV was 0.92, the NPV 0.84 and the concordance 87. Vaccination cards and centralized vaccination registries in primary health care centres and hospitals should be potentiated in order to ensure that neither more nor less vaccinations are administered than are necessary.

Nosocomial Outbreaks Caused by Leuconostoc mesenteroides subsp. mesenteroides.

From July 2003 through October 2004, 42 patients became infected by strains of Leuconostoc mesenteroides subsp. mesenteroides (genotype 1) in different departments of Juan Canalejo Hospital in northwest Spain. During 2006, 6 inpatients, also in different departments of the hospital, became infected (genotypes 2-4). Parenteral nutrition was the likely source.

Is the volume of blood cultured still a significant factor in the diagnosis of bloodstream infections?

"The higher the volume of blood cultured the higher the yield of blood cultures" has been a well-accepted dictum since J. A. Washington II performed his classic work. This rule has not been questioned in the era of highly automated blood culture machines, nor has it been correlated with clinical variables. Our objective in this study was to complete a prospective analysis of the relationship between blood volume, the yield of blood cultures, and the severity of clinical conditions in adult patients with suspected bloodstream infections (BSI). During a 6-month period, random samples of blood cultures were weighed to determine the volume of injected blood (weight/density). Overall, 298 patients with significant BSI and 303 patients with sepsis and negative blood cultures were studied. The mean volume of blood cultured in patients with BSI (30.03 +/- 14.96 ml [mean +/- standard deviation]) was lower than in patients without BSI (32.98 +/- 15.22 ml [P = 0.017]), and more episodes of bacteremia were detected with <20 ml (58.9%) than with >40 ml (40.2%) of blood cultured (P = 0.022). When patients were stratified according to the severity of their underlying condition, patients with BSI had higher APACHE II scores, and higher APACHE II scores were related to lower sample volumes (P < 0.001). A multivariate analysis showed that in the group of patients with APACHE II scores of >/=18, higher volumes yielded higher rates of bacteremia (odds ratio, 1.04 per ml of blood; 95% confidence interval, 1.001 to 1.08). We conclude that the higher yield of blood cultures inoculated with lower volumes of blood reflects the conditions of the population cultured. Washington's dictum holds true today in the era of automated blood culture machines.

Bloodstream infections: a trial of the impact of different methods of reporting positive blood culture results.

BACKGROUND: The impact of how positive blood culture results are reported on the evolution bloodstream infections (BSIs) has not been assessed. METHODS: We randomly assigned patients with BSIs into 3 groups: group A (for which physicians received a conventional report), group B (for which physicians received a conventional report and a written alert on the chart with clinical advice), and group C (for which physicians received the above plus oral clinical advice). The adequacy of therapy before and after receipt of the different types of information was assessed. RESULTS: Overall, 297 episodes (109 in group A, 99 in group B, and 89 in group C) were studied. Patients who received inadequate treatment before receiving microbiological information had a longer mean (+/-SD) hospital stay (27.2+/-32.4 vs. 19.4+/-15.8 days; P=.017), a higher mean risk of Clostridium difficile-associated diarrhea (8.3% vs. 1.9%; P=.013), a higher mean overall mortality rate (30.8% vs. 19.4%; P=.025), and a higher mean risk of infection-related mortality (23.3% vs. 13.6%; P=.031). After receipt of microbiological reports, recommendations for changes in therapy were issued for patients in groups B (52.3%) and C (53.1%). For groups A, B, and C, the proportions of days on which adequate treatment was received were 66.3%, 92.1%, and 91.2% (P<.001); the mean numbers of defined daily doses of appropriate antibiotic therapy were 16.4, 22.2, and 20.7 (P=.003); the mean durations of hospital stay were 19.8, 23.6, and 24.1 days (P=.761); and the mortality rates during the late period were 12.9%, 15.6%, and 11% (P=.670), respectively. The mean costs of antimicrobials per episode in groups A, B, and C were 580.63, 537.98, and 434.53 (US707.85 dollars, US699.73 dollars, and US529.73 dollars, respectively). CONCLUSIONS: Written- or oral-alert reports with clinical advice should complement traditional microbiological reports for patients with BSIs.