Pathological Findings Associated With SARS-CoV-2 on Postmortem Core Biopsies: Correlation With Clinical Presentation and Disease Course.

Background: Autopsies can shed light on the pathogenesis of new and emerging diseases. Aim: To describe needle core necropsy findings of the lung, heart, and liver in decedents with COVID-19. Material: Cross-sectional study of needle core necropsies in patients who died with virologically confirmed COVID-19. Histopathological analyses were performed, and clinical data and patient course evaluated. Results: Chest core necropsies were performed in 71 decedents with a median age of 81 years (range 52-97); 47 (65.3%) were men. The median interval from symptoms onset to death was 17.5 days (range 1-84). Samples of lung (n = 62, 87.3%), heart (n = 48, 67.6%) and liver (n = 39, 54.9%) were obtained. Fifty-one lung samples (82.3%) were abnormal: 19 (30.6%) showed proliferative diffuse alveolar damage (DAD), 12 (19.4%) presented exudative DAD, and 10 (16.1%) exhibited proliferative plus exudative DAD. Of the 46 lung samples tested for SARS-CoV-19 by RT-PCR, 39 (84.8%) were positive. DAD was associated with premortem values of lactate dehydrogenase of 400 U/L or higher [adjusted odds ratio (AOR) 21.73; 95% confidence interval (CI) 3.22-146] and treatment with tocilizumab (AOR 6.91; 95% CI 1.14-41.7). Proliferative DAD was associated with an onset-to-death interval of over 15 days (AOR 7.85, 95% CI 1.29-47.80). Twenty-three of the 48 (47.9%) heart samples were abnormal: all showed fiber hypertrophy, while 9 (18.8%) presented fibrosis. Of the liver samples, 29/39 (74.4%) were abnormal, due to steatosis (n = 12, 30.8%), cholestasis (n = 6, 15.4%) and lobular central necrosis (n = 5, 12.8%). Conclusion: Proliferative DAD was the main finding on lung core needle necropsy in people who died from COVID-19; this finding was related to a longer disease course. Changes in the liver and heart were common.

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

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.

EPICO 4.0. "Total quality" in the management of invasive candidiasis in critically ill patients by analysing the integrated process / ÉPICO 4.0. «Calidad total» en el manejo de la candidiasis invasiva en el paciente crítico mediante el análisis del proceso integrado

Background. A high quality integrated process in the clinical setting of non-neutropenic critically ill patients at risk for invasive candidiasis is a necessary tool to improve the management of these patients. Aims. To identify the key points on invasive candidiasis in order to develop a set of recommendations with a high level of consensus required for the creation of a total quality integrated process for the management of non-neutropenic critically ill patients at risk of invasive candidiasis. Methods. After a thorough review of the literature of the previous five years, a Spanish prospective questionnaire, which measured consensus by the Delphi technique, was anonymously conducted by e-mail, including 31 national multidisciplinary experts with extensive experience in invasive fungal infections, from six national scientific societies. The experts included a specialist in intensive care medicine, anesthetists, microbiologists, pharmacologists, and specialists in infectious diseases that responded 27 questions prepared by the coordination group. The educational objectives considered six processes that included knowledge of the local epidemiology, the creation and development of multidisciplinary teams, the definitions of the process, protocols, and indicators (KPI), an educational phase, hospital implementation, and the measurement of outcomes. The level of agreement among experts in each category to be selected should exceed 70%. In a second phase, after drawing up the recommendations of the selected processes, a face to face meeting with more than 60 specialists was held. The specialists were asked to validate the pre-selected recommendations. Measures and main outcomes. Firstly, 20 recommendations from all the sections were pre-selected: Knowledge of local epidemiology (3 recommendations), creation and development of multidisciplinary teams (3), definition of the process, protocols and indicators (1), educational phase (3), hospital implementation (3), and measurement of outcomes (7). After the second phase, 18 recommendations were validated, and it was concluded that the minimum team or core necessary for the development of an efficient program in the use of antifungal drugs in non-neutropenic critically ill patients must consist of a specialist in infectious diseases, a clinical pharmacist, a microbiologist, a specialist in intensive care medicine, a specialist in anesthesia and recovery, and an administrator or member of the medical management team, and, in order to be cost-effective, it should be implemented in hospitals with over 200 beds. In addition, it is recommended to apply a consensual check list for the evaluation of the diagnostic process and treatment of invasive candidiasis in patients that have started an antifungal treatment. The management of external knowledge and individual learning stand out as active educational strategies. The main strategies for measuring patient safety outcomes are the analysis of the results achieved, and learning activities; assess, review and refine the deployment of the processes; quality control; epidemiological surveillance and applied research; benchmarking; and basic research. The results of the integrated process should be annually disseminated outside the hospital. Conclusions. Optimizing the management of invasive candidiasis requires the application of the knowledge and skills detailed in our recommendations. These recommendations, based on the Delphi methodology, facilitate the creation of a total quality integrated process in critically-ill patients at risk for invasive candidiasis (AU)

Antecedentes. El adecuado manejo de los pacientes críticos no neutropénicos en situación de riesgo de contraer una candidiasis invasiva requiere la implementación de protocolos de alta calidad en la actuación clínica. Objetivos. Identificar los principales conocimientos y elaborar recomendaciones con un alto nivel de consenso, necesarios para la creación de un proceso integrado de calidad total para el manejo del paciente crítico no neutropénico con riesgo de candidiasis invasiva. Métodos. Se realizó un cuestionario prospectivo que mide el grado de consenso mediante la técnica Delphi, de forma anónima y por correo electrónico, entre 31 expertos multidisciplinarios, especialistas en infecciones fúngicas invasivas de seis sociedades científicas, que incluyen intensivistas, anestesistas, microbiólogos, farmacólogos y especialistas en enfermedades infecciosas que respondieron a 27 preguntas preparadas por el grupo de coordinación, tras una revisión exhaustiva de la literatura de los últimos cinco años. Los objetivos educativos contemplaron seis procesos, que incluían el conocimiento de la epidemiología local, la creación y el desarrollo de equipos multidisciplinares, la definición de proceso, protocolos e indicadores (KPI), una fase educacional, la implementación hospitalaria y la medición de resultados. El grado de acuerdo alcanzado entre los expertos en cada una de las categorías debía superar el 70% para ser seleccionada. Después de extraer las recomendaciones de los procesos escogidos, se celebró una reunión presencial con más de 60 especialistas y se les solicitó la validación de las recomendaciones preseleccionadas. Medidas y resultados principales. En un primer término se realizó una preselección de 20 recomendaciones de los siguientes apartados: Conocimiento de la epidemiología local (3), Creación y desarrollo de equipos multidisciplinares (3), Definición de proceso, protocolos e indicadores (1), Fase educacional (3), Implementación hospitalaria (3), Medición de resultados (7). Después de la segunda ronda se validaron 18 recomendaciones que se resumen en que el equipo mínimo (núcleo) necesario para un programa eficiente en el uso de fármacos antifúngicos para el paciente crítico no neutropénico debe estar integrado por un especialista en enfermedades infecciosas, un farmacéutico, un microbiólogo, un especialista en medicina intensiva, un especialista en anestesia y reanimación y un gestor o miembro de la dirección médica. Debería implementarse en hospitales de más de 200 camas para ser coste-efectivo. Además, se recomienda aplicar una lista de comprobación consensuada para la evaluación del proceso de diagnóstico y tratamiento de la candidiasis invasiva en los pacientes en los que se inicie un tratamiento antifúngico. Se destacan como estrategias de educación activa la gestión del conocimiento externo y del aprendizaje individual. Las principales estrategias para medir los resultados de seguridad del paciente son el análisis de los resultados obtenidos que comprenden la comprobación y revisión del proceso, control de calidad, vigilancia epidemiológica, benchmarking e investigación básica. Los resultados del proceso integrado deberían difundirse anualmente fuera del hospital. Conclusiones. La optimización del manejo de la candidiasis invasiva requiere de la aplicación de los conocimientos y destrezas que se detallan en nuestras recomendaciones. Estas recomendaciones basadas en la metodología Delphi, facilitan la creación de un proceso integrado de manejo con calidad total del paciente crítico con riesgo de candidiasis invasiva (AU)

EPICO 4.0. 'Total quality' in the management of invasive candidiasis in critically ill patients by analysing the integrated process.

BACKGROUND: A high quality integrated process in the clinical setting of non-neutropenic critically ill patients at risk for invasive candidiasis is a necessary tool to improve the management of these patients. AIMS: To identify the key points on invasive candidiasis in order to develop a set of recommendations with a high level of consensus required for the creation of a total quality integrated process for the management of non-neutropenic critically ill patients at risk of invasive candidiasis. METHODS: After a thorough review of the literature of the previous five years, a Spanish prospective questionnaire, which measured consensus by the Delphi technique, was anonymously conducted by e-mail, including 31 national multidisciplinary experts with extensive experience in invasive fungal infections, from six national scientific societies. The experts included a specialist in intensive care medicine, anesthetists, microbiologists, pharmacologists, and specialists in infectious diseases that responded 27 questions prepared by the coordination group. The educational objectives considered six processes that included knowledge of the local epidemiology, the creation and development of multidisciplinary teams, the definitions of the process, protocols, and indicators (KPI), an educational phase, hospital implementation, and the measurement of outcomes. The level of agreement among experts in each category to be selected should exceed 70%. In a second phase, after drawing up the recommendations of the selected processes, a face to face meeting with more than 60 specialists was held. The specialists were asked to validate the pre-selected recommendations. MEASURES AND MAIN OUTCOMES: Firstly, 20 recommendations from all the sections were pre-selected: Knowledge of local epidemiology (3 recommendations), creation and development of multidisciplinary teams (3), definition of the process, protocols and indicators (1), educational phase (3), hospital implementation (3), and measurement of outcomes (7). After the second phase, 18 recommendations were validated, and it was concluded that the minimum team or core necessary for the development of an efficient program in the use of antifungal drugs in non-neutropenic critically ill patients must consist of a specialist in infectious diseases, a clinical pharmacist, a microbiologist, a specialist in intensive care medicine, a specialist in anesthesia and recovery, and an administrator or member of the medical management team, and, in order to be cost-effective, it should be implemented in hospitals with over 200 beds. In addition, it is recommended to apply a consensual check list for the evaluation of the diagnostic process and treatment of invasive candidiasis in patients that have started an antifungal treatment. The management of external knowledge and individual learning stand out as active educational strategies. The main strategies for measuring patient safety outcomes are the analysis of the results achieved, and learning activities; assess, review and refine the deployment of the processes; quality control; epidemiological surveillance and applied research; benchmarking; and basic research. The results of the integrated process should be annually disseminated outside the hospital. CONCLUSIONS: Optimizing the management of invasive candidiasis requires the application of the knowledge and skills detailed in our recommendations. These recommendations, based on the Delphi methodology, facilitate the creation of a total quality integrated process in critically-ill patients at risk for invasive candidiasis.

EPICO 3.0. Antifungal prophylaxis in solid organ transplant recipients / EPICO 3.0. Profilaxis antifúngica en el paciente trasplantado de órgano sólido

Background. Although over the past decade the management of invasive fungal infection has improved, considerable controversy persists regarding antifungal prophylaxis in solid organ transplant recipients. Aims. To identify the key clinical knowledge and make by consensus the high level recommendations required for antifungal prophylaxis in solid organ transplant recipients. Methods. Spanish prospective questionnaire, which measures consensus through the Delphi technique, was conducted anonymously and by e-mail with 30 national multidisciplinary experts, specialists in invasive fungal infections from six national scientific societies, including intensivists, anesthetists, microbiologists, pharmacologists and specialists in infectious diseases that responded to 12 questions prepared by the coordination group, after an exhaustive review of the literature in the last few years. The level of agreement achieved among experts in each of the categories should be equal to or greater than 70% in order to make a clinical recommendation. In a second term, after extracting the recommendations of the selected topics, a face-to-face meeting was held with more than 60 specialists who were asked to validate the pre-selected recommendations and derived algorithm. Measurements and primary outcomes. Echinocandin antifungal prophylaxis should be considered in liver transplant with major risk factors (retransplantation, renal failure requiring dialysis after transplantation, pretransplant liver failure, not early reoperation, or MELD > 30); heart transplant with hemodialysis, and surgical re-exploration after transplantation; environmental colonization by Aspergillus, or cytomegalovirus (CMV) infection; and pancreas and intestinal transplant in case of acute graft rejection, hemodialysis, initial graft dysfunction, post-perfusion pancreatitis with anastomotic problems or need for laparotomy after transplantation. Antifungal fluconazole prophylaxis should be considered in liver transplant without major risk factors and MELD 20-30, split or living donor, choledochojejunostomy, increased transfusion requirements, renal failure without replacement therapy, early reoperation, or multifocal colonization or infection with Candida; intestinal and pancreas transplant with no risk factors for echinocandin treatment. Liposomal amphotericin B antifungal prophylaxis should be considered in lung transplant (inhalant form) and liver transplant with major risk factors. Antifungal prophylaxis with voriconazole should be considered in lung transplant, and heart transplant with hemodialysis, surgical re-exploration after transplantation, environmental colonization by Aspergillus, or CMV infection. Conclusions. The management of antifungal prophylaxis in solid organ transplant recipients requires the application of knowledge and skills that are detailed in our recommendations and the algorithm developed therein. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their management and improve overall prognosis (AU)

Antecedentes. Aunque en la última década se ha observado una mejora en el tratamiento de la infección fúngica invasiva, todavía existen numerosas controversias en la profilaxis antifúngica del paciente trasplantado de órgano sólido. Objetivos. Identificar los principales conocimientos clínicos y elaborar recomendaciones con un alto nivel de consenso, necesarias para la profilaxis antifúngica del paciente trasplantado de órgano sólido. Métodos. Se realizó un cuestionario prospectivo español, que valora el consenso mediante la técnica Delphi. El cuestionario se llevó a cabo de forma anónima y por correo electrónico con 30 expertos multidisciplinarios nacionales, especialistas en infecciones fúngicas invasivas de seis sociedades científicas nacionales, que incluían intensivistas, anestesistas, microbiólogos, farmacólogos y especialistas en enfermedades infecciosas que respondieron a 12 preguntas preparadas por el grupo de coordinación, tras una revisión exhaustiva de la bibliografía de los últimos años. El nivel de acuerdo alcanzado entre los expertos en cada una de las categorías debía ser igual o superior al 70% para elaborar una recomendación. En un segundo término, después de extraer las recomendaciones de los temas seleccionados, se celebró una reunión presencial con más de 60 especialistas y se les solicitó la validación de las recomendaciones preseleccionadas y del algoritmo derivado de estas. Mediciones y resultados principales. Debe considerarse la profilaxis antifúngica con equinocandinas en el trasplante hepático con los principales factores de riesgo (retrasplante, insuficiencia renal postrasplante con necesidad de diálisis, insuficiencia hepática pretrasplante, reintervención quirúrgica no precoz, o MELD > 30); trasplante cardíaco con hemodiálisis, y reexploración quirúrgica postrasplante; colonización ambiental por Aspergillus, o infección por citomegalovirus; trasplante de páncreas e intestino si existe rechazo agudo del injerto, hemodiálisis, disfunción inicial del injerto, problemas en la anastomosis con pancreatitis posperfusión, o necesidad de laparotomía postrasplante. Debe considerarse la profilaxis antifúngica con fluconazol en el trasplante hepático sin los principales factores de riesgo y MELD de 20-30, split o donante vivo, coledocoyeyunostomía, altos requerimientos transfusionales, fracaso renal sin necesidad de terapia sustitutiva, reintervención precoz o colonización multifocal o infección por Candida, y trasplante de páncreas e intestino sin factores de riesgo para el tratamiento con equinocandina. Debe considerarse la profilaxis antifúngica con anfotericina B liposómica en el trasplante pulmonar (vía inhalada) y el trasplante hepático con los principales factores de riesgo. Debe considerarse la profilaxis antifúngica con voriconazol en el trasplante pulmonar y el trasplante cardíaco con hemodiálisis, reexploración quirúrgica postrasplante, colonización ambiental por Aspergillus o enfermedad por citomegalovirus. Conclusiones. El manejo de la profilaxis antifúngica del paciente trasplantado de órgano sólido requiere la aplicación de los conocimientos y destrezas que se detallan en nuestras recomendaciones y en el algoritmo desarrollado. Estas recomendaciones basadas en la metodología Delphi pueden ayudar a identificar a los potenciales pacientes, estandarizar su tratamiento en conjunto y mejorar su pronóstico (AU)

EPICO 3.0. Recommendations on invasive candidiasis in patients with complicated intra-abdominal infection and surgical patients with ICU extended stay / EPICO 3.0. Recomendaciones para el manejo de la candidiasis invasiva en pacientes críticos con infección intraabdominal complicada y pacientes quirúrgicos de larga estancia en la UCI

Background. Although in the last decade the management of invasive fungal infections has improved, a number of controversies persist regarding the management of complicated intra-abdominal infection and surgical extended length-of-stay (LOS) patients in intensive care unit (ICU). Aims. To identify the essential clinical knowledge and elaborate a set of recommendations, with a high level of consensus, necessary for the management of postsurgical patients with complicated intra-abdominal infection and surgical patients with ICU extended stay. Methods. A Spanish prospective questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all of them specialists in fungal invasive infections from six scientific national societies; these experts were intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases. They answered 11 questions drafted by the coordination group after conducting a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each should be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting which was held after extracting recommendations from the chosen topics and in which they validated the pre-selected recommendations and derived algorithm. Results. After the second Delphi round, the following 11 recommendations with high degree of consensus were validated. For «surgical patients» seven recommendations were validated: (1) risk factors for invasive candidiasis (IC), (2) usefulness of blood culture and direct examination of abdominal fluid to start empirical treatment; (3) PCR for treatment discontinuation; (4) start antifungal treatment in patients with anastomotic leaks; (5) usefulness of Candida score (CS) but not (6) the Dupont score for initiating antifungal therapy in the event of anastomotic leakage or tertiary peritonitis, and (7) the administration of echinocandins as first line treatment in this special population. For «surgical ICU extended LOS patients» four recommendations were validated: (1) risk factors for IC, (2) presence of multi-colonization by Candida as a required variable of the CS, (3) starting antifungal treatment with CS≥4, and (4) to perform non-culture-based microbiological techniques in stable septic patients without evident focus. Conclusions. The diagnosis and management of IC in ICU surgical patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their global management and improve their outcomes (AU)

Antecedentes. Aunque en la última década se ha observado un mejor control de la infección fúngica invasiva, todavía existen numerosas controversias en el manejo del paciente posquirúrgico con infección intraabdominal complicada y del paciente quirúrgico de larga estancia en UCI. Objetivos. Identificar los principales conocimientos clínicos necesarios y elaborar recomendaciones con un alto nivel de consenso para el tratamiento del paciente posquirúrgico con infección intraabdominal complicada y del paciente quirúrgico de larga estancia en UCI. Métodos. Se realizó un cuestionario español prospectivo que mide el grado de consenso mediante la técnica Delphi. Dicho cuestionario fue realizado de forma anónima y por correo electrónico por 30 expertos multidisciplinarios nacionales, especialistas en infecciones fúngicas invasivas, de 6 sociedades científicas nacionales. Los expertos incluían intensivistas, anestesistas, microbiólogos, farmacólogos y especialistas en enfermedades infecciosas que respondieron a 11 preguntas preparadas por el grupo de coordinación, preguntas que fueron confeccionadas tras una revisión exhaustiva de la literatura de los últimos años. El grado de acuerdo alcanzado entre los expertos en cada una de las categorías debía ser igual o superior al 70% para redactar una recomendación. En un segundo término, después de extraer las recomendaciones de los temas seleccionados, se celebró una reunión presencial con 73 especialistas y se les solicitó la validación de las recomendaciones preseleccionadas y de los algoritmos derivados de estas. Resultados. Concluida la segunda ronda se validaron 11 recomendaciones con un elevado grado de consenso. Para los pacientes con infección intraabdominal complicada se validaron 7 recomendaciones: 1) factores de riesgo para la candidiasis invasiva; 2) utilidad del hemocultivo y del examen directo del líquido abdominal para iniciar tratamiento empírico; 3) PCR para la discontinuación del tratamiento; 4) inicio de tratamiento antifúngico en pacientes con dehiscencia de sutura anastomótica; 5) utilidad del Candida Score; 6) no utilidad de la escala de Dupont para el inicio de tratamiento antifúngico en caso de dehiscencia de sutura anastomótica o peritonitis terciaria, y 7) administración de equinocandinas como primera opción de tratamiento para esta población específica. Para los pacientes quirúrgicos de larga estancia en la UCI se validaron 4 recomendaciones: 1) factores de riesgo para candidiasis invasiva; 2) presencia de multicolonización por Candida como variable requerida del Candida Score; 3) inicio de tratamiento antifúngico si Candida Score≥4, y 4) determinación de técnicas microbiológicas no basadas en el cultivo en el paciente estable con sepsis sin foco evidente. Conclusiones. El diagnóstico y abordaje de la candidiasis invasiva en los pacientes quirúrgicos en UCI requiere de la aplicación del amplio conocimiento y habilidades establecidas en nuestras recomendaciones. Estas recomendaciones, basadas en la metodología Delphi, pueden ayudar a identificar a los potenciales pacientes, estandarizar su manejo en conjunto y mejorar sus resultados clínicos (AU)

EPICO 3.0. Empirical antifungal therapy in critically-ill hematology patients / EPICO 3.0. Tratamiento antifúngico empírico en pacientes hematológicos en estado crítico

Background. Although in the past decade the management of invasive fungal infections has improved, a number of controversies persist regarding empirical antifungal treatment in critically-ill hematology patients. Aims. To identify key clinical knowledge to elaborate a set of recommendations, with a high level of consensus, necessary for the approach to fungal infections in critically-ill hematology patients. Methods. A Spanish prospective questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all specialists in fungal invasive infections from six scientific national societies; intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases. They responded to 10 questions prepared by the coordination group after a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each category must be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting held after extracting the recommendations from the chosen topics, and validated the pre-selected recommendations and derived algorithm. Results. Assess administering antifungal treatment to patients with high/medium risk factors and fever for over 4 days after onset of antibiotic therapy, and in the event of negative galactomannan or if no detection analysis has been performed and no relevant findings in the sinus and chest computed tomography (CT) have been detected, (1) in the case the patient did not receive prophylaxis, or was administered fluconazole, caspofungin treatment is recommended; (2) in the event the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B is recommended and caspofungin as second choice therapy; (3) in the event that the prophylaxis received was an echinocandin, liposomal amphotericin B therapy is recommended and voriconazole as second choice. Assess administering antifungal treatment in patients with high/medium risk factors and fever for more than 4 days after onset of antibiotic therapy, and in the event of a positive galactomannan and/or sinus and chest CT suggests fungal infection caused by filamentous fungi, (1) in the event the patient did not receive antifungal prophylaxis or was administered fluconazole, the recommended treatment of choice is voriconazole or liposomal amphotericin B; (2) if the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B with caspofungin is recommended and monotherapy with liposomal amphotericin B or the combination of voriconazole and anidulafungin are recommended as second choice therapies; (3) in the event an echinocandin was administered as prophylaxis, liposomal amphotericin B or voriconazole are the recommended treatments of choice. Consider the administration of antifungal treatment in patients with high/medium risk factors and fever for more than 4 days after onset of antibiotic therapy, and in the event of a negative galactomannan and the sinus and chest CT suggests fungal infection caused by filamentous fungi, (1) if the patient did not receive prophylaxis or was administered fluconazole, the recommended treatment of choice is liposomal amphotericin B or voriconazole; (2) in the case the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B is recommended as first choice therapy and liposomal amphotericin B combined with caspofungin as second choice; (3) in the event an echinocandin was administered as prophylaxis, liposomal amphotericin B or voriconazole are the recommended treatments of choice. Conclusions. The empirical antifungal approach in critically-ill hematology patients requires the application of the broad range of knowledge and skills described in our recommendations and algorithm. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their management and improve overall prognosis (AU)

Antecedentes. Aunque en la última década se ha observado una mejora en el tratamiento de la micosis invasiva, todavía existen numerosas controversias en el tratamiento antifúngico empírico del paciente hematológico en estado crítico. Objetivos. Identificar los principales conocimientos clínicos y elaborar recomendaciones con un alto grado de consenso, necesarias para el abordaje de la micosis invasiva en el paciente hematológico en estado crítico. Métodos. Se ha empleado un cuestionario prospectivo español, que mide el consenso mediante la técnica Delphi. Se llevó a cabo de forma anónima y por correo electrónico con 30 expertos multidisciplinarios nacionales, especialistas en micosis invasivas de seis sociedades científicas nacionales, incluyendo intensivistas, anestesistas, microbiólogos, farmacólogos y especialistas en enfermedades infecciosas, los cuales respondieron a 10 preguntas preparadas por el grupo de coordinación, tras una revisión exhaustiva de la bibliografía de los últimos años. El grado de acuerdo alcanzado entre los expertos en cada una de las categorías debería ser igual o superior al 70% para ser seleccionada. En una segunda fase, después de extraer las recomendaciones de los temas seleccionados, se celebró una reunión presencial con 73 especialistas y se les solicitó la validación de las recomendaciones preseleccionadas y del algoritmo derivado de estas. Resultados. Se evalúa la administración de tratamiento antifúngico en pacientes hematológicos con factores de riesgo alto/medio y fiebre de más de 4 días después del inicio del tratamiento antibiótico si el galactomanano es negativo o no se ha realizado, y la TC de senos y tórax no aporta datos relevantes: 1) si no recibían profilaxis o era con fluconazol, se recomienda realizar un tratamiento con caspofungina; 2) en caso de que el paciente reciba profilaxis con un azol con actividad contra hongos filamentosos, la recomendación es la utilización de anfotericina B liposómica y como segunda opción, caspofungina, o 3) en el supuesto de que la profilaxis que reciba sea una equinocandina, la recomendación de tratamiento sería la anfotericina B liposómica y como alternativa el voriconazol. En pacientes con factores de riesgo alto/medio y fiebre de más de 4 días después del inicio del tratamiento antibiótico, si el galactomanano es positivo y/o la TC de senos y tórax sugiere infección por hongos filamentosos: 1) si el paciente no recibe profilaxis o es esta es con fluconazol, la recomendación es utilizar como tratamiento voriconazol o anfotericina B liposómica; 2) si la profilaxis que recibe es con un azol con acción contra hongos filamentosos, la recomendación es la utilización de anfotericina B liposómica con caspofungina y como alternativa anfotericina B liposómica en monoterapia o la combinación voriconazol con anidulafungina, o 3) si la profilaxis es con una equinocandina, la recomendación de tratamiento es emplear anfotericina B liposómica o voriconazol. En pacientes con factores de riesgo alto/medio y fiebre de más de 4 días después del inicio del tratamiento antibiótico, si el galactomanano es negativo y la TC de senos y tórax sugiere infección por hongos filamentosos: 1) si el paciente no recibe profilaxis o es con fluconazol, la recomendación es utilizar como tratamiento anfotericina B liposómica o voriconazol; 2) si la profilaxis que recibe es con un azol con acción contra hongos filamentosos, la recomendación es utilizar anfotericina B liposómica y como alternativa anfotericina B liposómica combinada con caspofungina, o 3) si la profilaxis es con una equinocandina, la recomendación de tratamiento es anfotericina B liposómica o voriconazol. Conclusiones. El abordaje del tratamiento antifúngico empírico del paciente crítico hematológico requiere la aplicación de los conocimientos y destrezas que se detallan en nuestras recomendaciones y en el algoritmo desarrollado. Estas recomendaciones basadas en la metodología Delphi pueden ayudar a identificar a los potenciales pacientes, estandarizar su tratamiento en conjunto y mejorar su pronóstico (AU)

EPICO 3.0. Management of non-neutropenic patients in medical wards / EPICO 3.0. Tratamiento del paciente no neutropénico en la planta de medicina interna

Background. Although the management of invasive fungal infection (IFI) has improved, a number of controversies persist regarding the approach to invasive fungal infection in non-neutropenic medical ward patients. Aims. To identify the essential clinical knowledge to elaborate a set of recommendations with a high level of consensus necessary for the management of IFI in non-neutropenic medical ward patients. Methods. A prospective, Spanish questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all specialists (intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases) in IFI and belonging to six scientific national societies. They responded to five questions prepared by the coordination group after a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each category had to be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting held after extracting the recommendations from the chosen topics, and validated the pre-selected recommendations and derived algorithm. Results. The following recommendations were validated and included in the algorithm: 1. several elements were identified as risk factors for invasive candidiasis (IC) in non-hematologic medical patients; 2. no agreement on the use of the colonization index to decide whether prescribing an early antifungal treatment to stable patients (no shock), with sepsis and no other evident focus and IC risk factors; 3. agreement on the use of the Candida Score to decide whether prescribing early antifungal treatment to stable patients (no shock) with sepsis and no other evident focus and IC risk factors; 4. agreement on initiating early antifungal treatment in stable patients (no shock) with a colonization index>0.4, sepsis with no other evident focus and IC risk factors; 5. agreement on the performance of additional procedures in stable patients (no shock) with sepsis and no other evident focus, IC risk factors, without colonization index>0.4, but with a high degree of suspicion. Conclusions. Based on the expert's recommendations, an algorithm for the management of non-neutropenic medical patients was constructed and validated. This algorithm may be useful to support bedside prescription (AU)

Antecedentes. A pesar de que el manejo de la micosis invasiva ha mejorado, persisten ciertas controversias en su tratamiento en pacientes no neutropénicos. Objetivos. Identificar el conocimiento clínico esencial y elaborar, con un alto nivel de consenso, las recomendaciones necesarias para el manejo de la micosis invasiva en pacientes no neutropénicos. Métodos. Treinta expertos multidisciplinarios españoles en micosis invasiva (intensivistas, anestesistas, microbiólogos, farmacólogos y especialistas en enfermedades infecciosas) pertenecientes a 6 sociedades científicas contestaron anónimamente un cuestionario que evaluaba el grado de consenso mediante la técnica Delphi. Los expertos respondieron a 5 preguntas elaboradas por los coordinadores después de una revisión exhaustiva de la bibligorafía reciente. El grado de acuerdo necesario para seleccionar una categoría fue igual o superior al 70%. Posteriormente, 73 especialistas asistieron a una reunión en que se extrajeron las recomendaciones que se utilizaron en la elaboración de un algoritmo para la ayuda en la toma de una decisión clínica. Resultados. Las recomendaciones validadas e incluidas en el algoritmo fueron las siguientes: 1) varias situaciones se definieron como factores de riesgo para la candidiasis invasiva (CI) en pacientes no hematológicos; 2) no hubo acuerdo sobre el uso del índice de colonización para decidir la prescripción de tratamiento antifúngico precoz en pacientes estables (sin shock) con septicemia, sin foco evidente y con factores de riesgo para CI; 3) hubo acuerdo en el uso del Candida Score para decidir la prescripción de tratamiento antifúngico precoz en pacientes estables (sin shock) con septicemia, sin foco evidente y con factores de riesgo para CI; 4) hubo acuerdo en el inicio de tratamiento antifúngico precoz en pacientes estables (sin shock) con sepsis, sin foco evidente e índice de colonización >0,4 y con factores de riesgo para CI; 5) hubo acuerdo para realizar los procedimientos diagnósticos adicionales en pacientes estables (sin shock) con septicemia, sin foco evidente, factores de riesgo para CI e índice de colonización <0,4, pero con alto índice de sospecha. Conclusiones. Se ha elaborado un algoritmo de manejo de la CI en pacientes no neutropénicos basado en las recomendaciones de expertos. Este algoritmo puede ser útil como soporte a la prescripción a pie de cama (AU)

EPICO 3.0. Empirical antifungal therapy in critically-ill hematology patients.

BACKGROUND: Although in the past decade the management of invasive fungal infections has improved, a number of controversies persist regarding empirical antifungal treatment in critically-ill hematology patients. AIMS: To identify key clinical knowledge to elaborate a set of recommendations, with a high level of consensus, necessary for the approach to fungal infections in critically-ill hematology patients. METHODS: A Spanish prospective questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all specialists in fungal invasive infections from six scientific national societies; intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases. They responded to 10 questions prepared by the coordination group after a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each category must be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting held after extracting the recommendations from the chosen topics, and validated the pre-selected recommendations and derived algorithm. RESULTS: Assess administering antifungal treatment to patients with high/medium risk factors and fever for over 4 days after onset of antibiotic therapy, and in the event of negative galactomannan or if no detection analysis has been performed and no relevant findings in the sinus and chest computed tomography (CT) have been detected, (1) in the case the patient did not receive prophylaxis, or was administered fluconazole, caspofungin treatment is recommended; (2) in the event the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B is recommended and caspofungin as second choice therapy; (3) in the event that the prophylaxis received was an echinocandin, liposomal amphotericin B therapy is recommended and voriconazole as second choice. Assess administering antifungal treatment in patients with high/medium risk factors and fever for more than 4 days after onset of antibiotic therapy, and in the event of a positive galactomannan and/or sinus and chest CT suggests fungal infection caused by filamentous fungi, (1) in the event the patient did not receive antifungal prophylaxis or was administered fluconazole, the recommended treatment of choice is voriconazole or liposomal amphotericin B; (2) if the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B with caspofungin is recommended and monotherapy with liposomal amphotericin B or the combination of voriconazole and anidulafungin are recommended as second choice therapies; (3) in the event an echinocandin was administered as prophylaxis, liposomal amphotericin B or voriconazole are the recommended treatments of choice. Consider the administration of antifungal treatment in patients with high/medium risk factors and fever for more than 4 days after onset of antibiotic therapy, and in the event of a negative galactomannan and the sinus and chest CT suggests fungal infection caused by filamentous fungi, (1) if the patient did not receive prophylaxis or was administered fluconazole, the recommended treatment of choice is liposomal amphotericin B or voriconazole; (2) in the case the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B is recommended as first choice therapy and liposomal amphotericin B combined with caspofungin as second choice; (3) in the event an echinocandin was administered as prophylaxis, liposomal amphotericin B or voriconazole are the recommended treatments of choice. CONCLUSIONS: The empirical antifungal approach in critically-ill hematology patients requires the application of the broad range of knowledge and skills described in our recommendations and algorithm. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their management and improve overall prognosis.

EPICO 3.0. Management of non-neutropenic patients in medical wards.

BACKGROUND: Although the management of invasive fungal infection (IFI) has improved, a number of controversies persist regarding the approach to invasive fungal infection in non-neutropenic medical ward patients. AIMS: To identify the essential clinical knowledge to elaborate a set of recommendations with a high level of consensus necessary for the management of IFI in non-neutropenic medical ward patients. METHODS: A prospective, Spanish questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all specialists (intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases) in IFI and belonging to six scientific national societies. They responded to five questions prepared by the coordination group after a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each category had to be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting held after extracting the recommendations from the chosen topics, and validated the pre-selected recommendations and derived algorithm. RESULTS: The following recommendations were validated and included in the algorithm: 1. several elements were identified as risk factors for invasive candidiasis (IC) in non-hematologic medical patients; 2. no agreement on the use of the colonization index to decide whether prescribing an early antifungal treatment to stable patients (no shock), with sepsis and no other evident focus and IC risk factors; 3. agreement on the use of the Candida Score to decide whether prescribing early antifungal treatment to stable patients (no shock) with sepsis and no other evident focus and IC risk factors; 4. agreement on initiating early antifungal treatment in stable patients (no shock) with a colonization index>0.4, sepsis with no other evident focus and IC risk factors; 5. agreement on the performance of additional procedures in stable patients (no shock) with sepsis and no other evident focus, IC risk factors, without colonization index>0.4, but with a high degree of suspicion. CONCLUSIONS: Based on the expert's recommendations, an algorithm for the management of non-neutropenic medical patients was constructed and validated. This algorithm may be useful to support bedside prescription.

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)

EPICO 3.0. Recommendations on invasive candidiasis in patients with complicated intra-abdominal infection and surgical patients with ICU extended stay.

BACKGROUND: Although in the last decade the management of invasive fungal infections has improved, a number of controversies persist regarding the management of complicated intra-abdominal infection and surgical extended length-of-stay (LOS) patients in intensive care unit (ICU). AIMS: To identify the essential clinical knowledge and elaborate a set of recommendations, with a high level of consensus, necessary for the management of postsurgical patients with complicated intra-abdominal infection and surgical patients with ICU extended stay. METHODS: A Spanish prospective questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all of them specialists in fungal invasive infections from six scientific national societies; these experts were intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases. They answered 11 questions drafted by the coordination group after conducting a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each should be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting which was held after extracting recommendations from the chosen topics and in which they validated the pre-selected recommendations and derived algorithm. RESULTS: After the second Delphi round, the following 11 recommendations with high degree of consensus were validated. For "surgical patients" seven recommendations were validated: (1) risk factors for invasive candidiasis (IC), (2) usefulness of blood culture and direct examination of abdominal fluid to start empirical treatment; (3) PCR for treatment discontinuation; (4) start antifungal treatment in patients with anastomotic leaks; (5) usefulness of Candida score (CS) but not (6) the Dupont score for initiating antifungal therapy in the event of anastomotic leakage or tertiary peritonitis, and (7) the administration of echinocandins as first line treatment in this special population. For "surgical ICU extended LOS patients" four recommendations were validated: (1) risk factors for IC, (2) presence of multi-colonization by Candida as a required variable of the CS, (3) starting antifungal treatment with CS≥4, and (4) to perform non-culture-based microbiological techniques in stable septic patients without evident focus. CONCLUSIONS: The diagnosis and management of IC in ICU surgical patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their global management and improve their outcomes.

EPICO 3.0. Antifungal prophylaxis in solid organ transplant recipients.

BACKGROUND: Although over the past decade the management of invasive fungal infection has improved, considerable controversy persists regarding antifungal prophylaxis in solid organ transplant recipients. AIMS: To identify the key clinical knowledge and make by consensus the high level recommendations required for antifungal prophylaxis in solid organ transplant recipients. METHODS: Spanish prospective questionnaire, which measures consensus through the Delphi technique, was conducted anonymously and by e-mail with 30 national multidisciplinary experts, specialists in invasive fungal infections from six national scientific societies, including intensivists, anesthetists, microbiologists, pharmacologists and specialists in infectious diseases that responded to 12 questions prepared by the coordination group, after an exhaustive review of the literature in the last few years. The level of agreement achieved among experts in each of the categories should be equal to or greater than 70% in order to make a clinical recommendation. In a second term, after extracting the recommendations of the selected topics, a face-to-face meeting was held with more than 60 specialists who were asked to validate the pre-selected recommendations and derived algorithm. MEASUREMENTS AND PRIMARY OUTCOMES: Echinocandin antifungal prophylaxis should be considered in liver transplant with major risk factors (retransplantation, renal failure requiring dialysis after transplantation, pretransplant liver failure, not early reoperation, or MELD>30); heart transplant with hemodialysis, and surgical re-exploration after transplantation; environmental colonization by Aspergillus, or cytomegalovirus (CMV) infection; and pancreas and intestinal transplant in case of acute graft rejection, hemodialysis, initial graft dysfunction, post-perfusion pancreatitis with anastomotic problems or need for laparotomy after transplantation. Antifungal fluconazole prophylaxis should be considered in liver transplant without major risk factors and MELD 20-30, split or living donor, choledochojejunostomy, increased transfusion requirements, renal failure without replacement therapy, early reoperation, or multifocal colonization or infection with Candida; intestinal and pancreas transplant with no risk factors for echinocandin treatment. Liposomal amphotericin B antifungal prophylaxis should be considered in lung transplant (inhalant form) and liver transplant with major risk factors. Antifungal prophylaxis with voriconazole should be considered in lung transplant, and heart transplant with hemodialysis, surgical re-exploration after transplantation, environmental colonization by Aspergillus, or CMV infection. CONCLUSIONS: The management of antifungal prophylaxis in solid organ transplant recipients requires the application of knowledge and skills that are detailed in our recommendations and the algorithm developed therein. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their management and improve overall prognosis.