Implementación de un programa para mitigar la resistencia a los antimicrobianos en escenarios de bajos recursos / Implementation of a program to face antimicrobial resistance on a low resources hospital

Estudio cuasi-experimental desarrollado para disminuir el impacto de la resistencia a los antimicrobianos a través de un programa de prevención de infecciones y optimización del uso de antimicrobianos construido "a medida" según las posibilidades de la institución. Se implementó: vigilan-cia de colonización e infección por enterobacterias pro-ductoras de carbapenemasas (EPC); vigilancia y medidas preventivas para infecciones urinarias asociadas a sonda vesical (ITU); vigilancia e intervenciones para mejorar la higiene de manos; guías locales de tratamiento de enfer-medades infecciosas con evaluación de adherencia a las mismas y consumo de antibióticos (ATB). Resultados: Comparando periodo pre y postintervención: tasa de EPC en muestras clínicas: 1,1 a 0/días paciente; razón de tasas de incidencia (IRR: 0.00, p: 0.033); tasa de colonización: 3,3 a 0,61/días paciente (IRR: 0.18, p: 0.5). Tasa de ITU 8,9 a 7,2/1000 días catéter urinario (IRR: 0.81, p 0.5). Adherencia a higiene de manos: 77,5% a 70,38% (p 0.0067). Consumo de ATB: 376,24 a 176,82 DDD, (disminu-ción 53%). Adherencia a guías en elección de ATB: 57,1% a 95,4% (p 0.00031); duración de ATB: 92,8% a 98,4% (p 0.16); adecuación según rescate microbiológico: 57,1% a 100% (p <0.01). Conclusión: Un programa con medidas simples, a medida, con supervisión externa, redujo en un tiempo relativamente corto las infecciones por EPC, el consumo y uso apropiado de ATB en un hospital público de medianos/bajos recursos

This quasi-experimental study was developed in a public hospital with the goal of reducing the impact of antimicrobial resistance through an infection prevention and antimicrobial stewardship program. The following measures were implemented: surveillance of colonization and infection by carbapenemase-producing Enterobacteriaceae (CPE); surveillance and preventive measures for urinary catheter-associated infections (UTIs); surveillance and interventions for hand hygiene; local guidelines for treatment of infectious diseases with compliance and antibiotic (ATB) consumption metrics.Results: comparing the pre-intervention and post-intervention period, CPE rate in clinical samples 1.1 to 0/patient days, incidence rate ratio (IRR): 0.00, p: 0.033 and colonization of 3.3 to 0.61/days patient, IRR: 0.18, p-value: 0.5. UTI rate 8.9 to 7.2/1000 days urinary catheter IRR: 0.81, p 0.5. Hand Hygiene compliance: 77.5% to 70.38%, p 0.0067. ATB consumption: 376.24 to 176.82 DDD, 53% decrease. Compliance to guidelines in ATB selection: 57.1% to 95.4% p 0.00031, duration of ATB from 92.8% to 98.4% p 0.16, and adequacy to microbiological rescue of 57.1% at 100%, p <0.01. Conclusion: it is possible to reduce CPE infections, the consumption of antimicrobials and optimize their use in a public hospital in a country with medium/low resources through a program with basic and tailored measures

Infective endocarditis in pregnant women without intravenous drug use: a multicentre retrospective case series.

OBJECTIVES: To describe the clinical features and outcomes of infective endocarditis (IE) in pregnant women who do not inject drugs. METHODS: A multinational retrospective study was performed at 14 hospitals. All definite IE episodes between January 2000 and April 2021 were included. The main outcomes were maternal mortality and pregnancy-related complications. RESULTS: Twenty-five episodes of IE were included. Median age at IE diagnosis was 33.2 years (IQR 28.3-36.6) and median gestational age was 30 weeks (IQR 16-32). Thirteen (52%) patients had no previously known heart disease. Sixteen (64%) were native IE, 7 (28%) prosthetic and 2 (8%) cardiac implantable electronic device IE. The most common aetiologies were streptococci (n = 10, 40%), staphylococci (n = 5, 20%), HACEK group (n = 3, 12%) and Enterococcus faecalis (n = 3, 12%). Twenty (80%) patients presented at least one IE complication; the most common were heart failure (n = 13, 52%) and symptomatic embolism other than stroke (n = 4, 16%). Twenty-one (84%) patients had surgery indication and surgery was performed when indicated in 19 (90%). There was one maternal death and 16 (64%) patients presented pregnancy-related complications (11 patients ≥1 complication): 3 pregnancy losses, 9 urgent Caesarean sections, 2 emergency Caesarean sections, 1 fetal death, and 11 preterm births. Two patients presented a relapse during a median follow-up of 3.1 years (IQR 0.6-7.4). CONCLUSIONS: Strict medical surveillance of pregnant women with IE is required and must involve a multidisciplinary team including obstetricians and neonatologists. Furthermore, the potential risk of IE during pregnancy should never be underestimated in women with previously known underlying heart disease.

Consenso de recomendaciones de vacunas en adultos con enfermedades reumáticas inflamatorias crónicas autoinmunes / Consensus of vaccine recommendations in adults with autoimmune chronic inflammatory rheumatic diseases

Las enfermedades reumáticas inflamatorias crónicas autoinmunes (ERICA) son un conjunto de patologías que se caracterizan por compromiso articular y sistémico, que frecuentemente generan dolor, discapacidad funcional y deterioro en la calidad de vida. Entre ellas se destacan: la artritis reumatoidea, el lupus eritematoso sistémico, la esclerodermia, la miopatía inflamatoria, la espondiloartritis, las vasculitis, entre otras. La mayoría de las enfermedades reumáticas tiene un importante componente autoinflamatorio, con una marcada desregulación de varios aspectos del sistema inmune. Uno de estos es la autoinmunidad, la cual puede definirse como la aparición de una respuesta inmune humoral y/o celular contra proteínas propias (autoantígenos) localizadas en diversos tejidos. Actualmente se considera que las enfermedades autoinmunes son desórdenes multifactoriales que muestran una complejidad y heterogeneidad considerable a pesar de tener una patogénesis en común: la pérdida de la autotolerancia.

Consenso de inmunizaciones en adultos con enfermedades reumáticas inflamatorias crónicas autoinmunes / Consensus on immunizations in adults with autoimmune chronic inflammatory rheumatic diseases

Aumento del riesgo de infecciones prevenibles y sus complicaciones en pacientes con enfermedades reumáticas inflamatorias crónicas (ERICA), con y sin tratamiento con inmunosupresores (IS), y beneficios de la vacunación.

Prospective Cohort Study of Infective Endocarditis in People Who Inject Drugs.

BACKGROUND: Infective endocarditis (IE) in people who inject drugs (PWID) is an emergent public health problem. OBJECTIVES: The purpose of this study was to investigate IE in PWID and compare it with IE in non-PWID patients. METHODS: Two prospective cohort studies (ICE-PCS and ICE-Plus databases, encompassing 8,112 IE episodes from 2000 to 2006 and 2008 to 2012, with 64 and 34 sites and 28 and 18 countries, respectively). Outcomes were compared between PWID and non-PWID patients with IE. Logistic regression analyses were performed to investigate risk factors for 6-month mortality and relapses amongst PWID. RESULTS: A total of 7,616 patients (591 PWID and 7,025 non-PWID) were included. PWID patients were significantly younger (median 37.0 years [interquartile range: 29.5 to 44.2 years] vs. 63.3 years [interquartile range: 49.3 to 74.0 years]; p < 0.001), male (72.5% vs. 67.4%; p = 0.007), and presented lower rates of comorbidities except for human immunodeficiency virus, liver disease, and higher rates of prior IE. Amongst IE cases in PWID, 313 (53%) episodes involved left-side valves and 204 (34.5%) were purely left-sided IE. PWID presented a larger proportion of native IE (90.2% vs. 64.4%; p < 0.001), whereas prosthetic-IE and cardiovascular implantable electronic device-IE were more frequent in non-PWID (9.3% vs. 27.0% and 0.5% vs. 8.6%; both p < 0.001). Staphylococcus aureus caused 65.9% and 26.8% of cases in PWID and non-PWID, respectively (p < 0.001). PWID presented higher rates of systemic emboli (51.1% vs. 22.5%; p < 0.001) and persistent bacteremia (14.7% vs. 9.3%; p < 0.001). Cardiac surgery was less frequently performed (39.5% vs. 47.8%; p < 0.001), and in-hospital and 6-month mortality were lower in PWID (10.8% vs. 18.2% and 14.4% vs. 22.2%; both p < 0.001), whereas relapses were more frequent in PWID (9.5% vs. 2.8%; p < 0.001). Prior IE, left-sided IE, polymicrobial etiology, intracardiac complications, and stroke were risk factors for 6-month mortality, whereas cardiac surgery was associated with lower mortality in the PWID population. CONCLUSIONS: A notable proportion of cases in PWID involve left-sided valves, prosthetic valves, or are caused by microorganisms other than S. aureus.

[Immunizations in adults with cardiovascular disease. Summary of the Consensus of the Argentine Cardiology Society]. / Inmunizaciones en adultos con cardiopatías. Resumen del Consenso de la Sociedad Argentina de Cardiología.

Cardiovascular diseases are the leading cause of death in most regions of the world, usually followed by infectious diseases. For decades, infections in general, and particularly those involving the respiratory system, have been known to be associated with an increased risk of cardiovascular and cerebrovascular events, and their consequent morbidity and mortality. Although vaccines are an excellent strategy in the prevention of infectious diseases, the proportion of immunized adults in our country is frankly deficient. Multiple barriers contribute to perpetuating this problem, within which the lack of prescription of the same by professionals who care for vulnerable populations occupies a central place. Patients with cardiovascular disease represent a particularly risky subpopulation. The spectrum of pathologies that can trigger respiratory infections is wide: development or worsening of heart failure, arrhythmias, acute coronary syndromes and cerebrovascular diseases, among the main ones. The role of immunoprophylaxis with influenza, pneumococcal and tetanus vaccine in patients with different heart diseases is addressed here, evaluating the evidence supporting its use, and placing special emphasis on practical aspects of its use, such as adverse effects, contraindications and special care situations, such as congenital heart disease in adults, heart transplantation, anticoagulation or egg allergy. Thus, this document aims to assist in decision-making for any doctor involved in the care of patients with cardiovascular disease.

Las enfermedades cardiovasculares ocupan la primera causa de muerte en la mayoría de las regiones del mundo, seguidas habitualmente por las enfermedades infecciosas. Desde hace décadas se conoce que las infecciones en general, y particularmente las que involucran el aparato respiratorio, se vinculan con un incremento en el riesgo de eventos cardiovasculares y cerebrovasculares, y su consecuente morbimortalidad. Si bien las vacunas constituyen una excelente estrategia en la prevención de enfermedades infectocontagiosas, la proporción de adultos inmunizados en nuestro país es francamente deficitaria. Múltiples barreras contribuyen a perpetuar esta problemática, dentro de las cuales la falta de prescripción de las mismas por parte de los profesionales que atienden a poblaciones vulnerables ocupa un lugar central. Los pacientes con enfermedades cardiovasculares representan una subpoblación de particular riesgo. El espectro de enfermedades que pueden originar las infecciones respiratorias es amplio: desarrollo o empeoramiento de insuficiencia cardíaca, arritmias, síndromes coronarios agudos y enfermedades cerebrovasculares, entre los principales. Se aborda aquí el rol de la inmunoprofilaxis con vacuna antigripal, antineumocócica y antitetánica en pacientes con diferentes cardiopatías, valorando la evidencia que respalda su empleo y haciendo especial hincapié en aspectos prácticos de su utilización, como efectos adversos, contraindicaciones y situaciones especiales de atención: cardiopatías congénitas del adulto, trasplante cardíaco, individuos anticoagulados o con alergia al huevo. Así, este documento tiene como objetivo asistir en la toma de decisiones a cualquier médico involucrado en el cuidado de pacientes con enfermedad cardiovascular.

Inmunizaciones en adultos con cardiopatías. Resumen del consenso de la Sociedad Argentina de Cardiología / Immunizations in adults with cardiovascular disease. Summary of the Consensus of the Argentine Cardiology Society

Resumen Las enfermedades cardiovasculares ocupan la primera causa de muerte en la mayoría de las regiones del mundo, seguidas habitualmente por las enfermedades infecciosas. Desde hace décadas se conoce que las infecciones en general, y particularmente las que involucran el aparato respiratorio, se vinculan con un incremento en el riesgo de eventos cardiovasculares y cerebrovasculares, y su consecuente morbimortalidad. Si bien las vacunas constituyen una excelente estrategia en la prevención de enfermedades infectocontagiosas, la proporción de adultos inmunizados en nuestro país es francamente deficitaria. Múltiples barreras contribuyen a perpetuar esta problemática, dentro de las cuales la falta de prescripción de las mismas por parte de los profesionales que atienden a poblaciones vulnerables ocupa un lugar central. Los pacientes con enfermedades cardiovasculares representan una subpoblación de particular riesgo. El espectro de enfermedades que pueden originar las infecciones respiratorias es amplio: desarrollo o empeoramiento de insuficiencia cardíaca, arritmias, síndromes coronarios agudos y enfermedades cerebrovasculares, entre los principales. Se aborda aquí el rol de la inmunoprofilaxis con vacuna antigripal, antineumocócica y antitetánica en pacientes con diferentes cardiopatías, valorando la evidencia que respalda su empleo y haciendo especial hincapié en aspectos prácticos de su utilización, como efectos adversos, contraindicaciones y situaciones especiales de atención: cardiopatías congénitas del adulto, trasplante cardíaco, individuos anticoagulados o con alergia al huevo. Así, este documento tiene como objetivo asistir en la toma de decisiones a cualquier médico involucrado en el cuidado de pacientes con enfermedad cardiovascular.

Abstract Cardiovascular diseases are the leading cause of death in most regions of the world, usually followed by infectious diseases. For decades, infections in general, and particularly those involving the respiratory system, have been known to be associated with an increased risk of cardiovascular and cerebrovascular events, and their consequent morbidity and mortality. Although vaccines are an excellent strategy in the prevention of infectious diseases, the proportion of immunized adults in our country is frankly deficient. Multiple barriers contribute to perpetuating this problem, within which the lack of prescription of the same by professionals who care for vulnerable populations occupies a central place. Patients with cardiovascular disease represent a particularly risky subpopulation. The spectrum of pathologies that can trigger respiratory infections is wide: development or worsening of heart failure, arrhythmias, acute coronary syndromes and cerebrovascular diseases, among the main ones. The role of immunoprophylaxis with influenza, pneumococcal and tetanus vaccine in patients with different heart diseases is addressed here, evaluating the evidence supporting its use, and placing special emphasis on practical aspects of its use, such as adverse effects, contraindications and special care situations, such as congenital heart disease in adults, heart transplantation, anticoagulation or egg allergy. Thus, this document aims to assist in decision-making for any doctor involved in the care of patients with cardiovascular disease.

[Positron emission tomography in infective endocarditis associated with intracardiac devices and prosthetic valves]. / Tomografía por emisión de positrones en endocarditis infecciosa asociada a dispositivos y válvulas protésicas.

Infective endocarditis (IE) is a serious and potentially lethal condition. The diagnostic capacity of the modified Duke criteria is high for native valves, but it declines in the case of EI of prosthetic valves or EI associated with devices. Echocardiography and microbiological findings are essential for diagnosis but may be insufficient in this group of patients. Our objective was to evaluate the usefulness of positron emission tomography and fusion with computed tomography (PET / CT) in patients with suspected IE, carriers of prosthetic valves or intracardiac devices; 32 patients were studied, who underwent PET / CT with 18F-Fluorine deoxyglucose (18F-FDG). Those with intense focal and/or heterogeneous uptake with a Standard Uptake Value SUV) cut-off point greater than or equal to 3.7 were considered suggestive of infection. The initial diagnoses according to the modified Duke criteria were compared with the final diagnosis established by the Institutional Endocarditis Unit. The addition of PET / CT to these criteria, provided a conclusive diagnosis in 22 of the 32 initial cases reclassifying 11 cases in definitive EI; another 5 cases were negative for that diagnosis. EI continues to be a serious clinical problem. In those cases where the Duke criteria are not sufficient to establish the diagnosis and clinical suspicion persists, PET / CT can be a useful complementary tool to increase the diagnostic sensitivity.

La endocarditis infecciosa (EI) es una enfermedad grave y potencialmente letal. La capacidad diagnóstica de los criterios de Duke modificados es alta para válvulas nativas, pero decae en el caso de EI de válvulas protésicas o EI asociadas a dispositivos. El ecocardiograma y los hallazgos microbiológicos son fundamentales para el diagnóstico, pero pueden resultar insuficientes en este grupo de pacientes. Nuestro objetivo fue evaluar la utilidad de la tomografía por emisión de positrones y fusión con tomografía computarizada (PET/TC) en pacientes con sospecha de EI, portadores de válvulas protésicas o dispositivos intracardiacos. Se estudiaron 32 pacientes, a los cuales se les realizó un PET/CT con 18F-Flúor desoxiglucosa (18F-FDG). Se consideraron sugestivos de infección aquellos con captación intensa de tipo focal y/o heterogénea con un punto de corte de Standard Uptake Value (SUV) mayor o igual a 3.7. Los diagnósticos iniciales según los criterios de Duke modificados, se compararon con el diagnóstico final establecido por la Unidad de Endocarditis institucional. El agregado del PET/CT a esos criterios, proporcionó un diagnóstico concluyente en 22 de los 32 casos iniciales, reclasificando a 11 casos en EI definitivas y a otros 5 casos como negativos para ese diagnóstico. La EI continúa siendo un grave problema clínico. En aquellos casos donde los criterios de Duke no son suficientes para establecer el diagnóstico y la sospecha clínica persiste, el PET/CT puede ser una herramienta complementaria útil para aumentar la sensibilidad diagnóstica.

Tomografía por emisión de positrones en endocarditis infecciosa asociada a dispositivos y válvulas protésicas / Positron emission tomography in infective endocarditis associated with intracardiac devices and prosthetic valves

La endocarditis infecciosa (EI) es una enfermedad grave y potencialmente letal. La capacidad diagnóstica de los criterios de Duke modificados es alta para válvulas nativas, pero decae en el caso de EI de válvulas protésicas o EI asociadas a dispositivos. El ecocardiograma y los hallazgos microbiológicos son fundamentales para el diagnóstico, pero pueden resultar insuficientes en este grupo de pacientes. Nuestro objetivo fue evaluar la utilidad de la tomografía por emisión de positrones y fusión con tomografía computarizada (PET/TC) en pacientes con sospecha de EI, portadores de válvulas protésicas o dispositivos intracardiacos. Se estudiaron 32 pacientes, a los cuales se les realizó un PET/CT con 18F-Flúor desoxiglucosa (18F-FDG). Se consideraron sugestivos de infección aquellos con captación intensa de tipo focal y/o heterogénea con un punto de corte de Standard Uptake Value (SUV) mayor o igual a 3.7. Los diagnósticos iniciales según los criterios de Duke modificados, se compararon con el diagnóstico final establecido por la Unidad de Endocarditis institucional. El agregado del PET/CT a esos criterios, proporcionó un diagnóstico concluyente en 22 de los 32 casos iniciales, reclasificando a 11 casos en EI definitivas y a otros 5 casos como negativos para ese diagnóstico. La EI continúa siendo un grave problema clínico. En aquellos casos donde los criterios de Duke no son suficientes para establecer el diagnóstico y la sospecha clínica persiste, el PET/CT puede ser una herramienta complementaria útil para aumentar la sensibilidad diagnóstica.

Infective endocarditis (IE) is a serious and potentially lethal condition. The diagnostic capacity of the modified Duke criteria is high for native valves, but it declines in the case of EI of prosthetic valves or EI associated with devices. Echocardiography and microbiological findings are essential for diagnosis but may be insufficient in this group of patients. Our objective was to evaluate the usefulness of positron emission tomography and fusion with computed tomography (PET / CT) in patients with suspected IE, carriers of prosthetic valves or intracardiac devices; 32 patients were studied, who underwent PET / CT with 18F-Fluorine deoxyglucose (18F-FDG). Those with intense focal and/or heterogeneous uptake with a Standard Uptake Value (SUV) cut-off point greater than or equal to 3.7 were considered suggestive of infection. The initial diagnoses according to the modified Duke criteria were compared with the final diagnosis established by the Institutional Endocarditis Unit. The addition of PET / CT to these criteria, provided a conclusive diagnosis in 22 of the 32 initial cases reclassifying 11 cases in definitive EI; another 5 cases were negative for that diagnosis. EI continues to be a serious clinical problem. In those cases where the Duke criteria are not sufficient to establish the diagnosis and clinical suspicion persists, PET / CT can be a useful complementary tool to increase the diagnostic sensitivity.

[Infective endocarditis in Argentina: what have we learned in the last 25 years ?] / Endocarditis infecciosa en Argentina: ¿ qué aprendimos en los últimos 25 años ?

The epidemiology of infectious endocarditis (IE) has undergone changes due to a series of factors such as aging, comorbidities and medical procedures. The aim of this study was to evaluate the main clinical, epidemiological and etiological changes of the IE in the last 25 years in Argentina. A comparative analysis of three observational prospective registries was performed in which cases of definite and possible IE were consecutively included according to the Duke criteria: two multicentre studies (EIRA-1 [1992-1994] and EIRA-2 [2001-2002]) and one study in a reference cardiology center (CRC [2007-2017]). In the 1065 episodes of EI evaluated, there were no differences regarding sex, and the patients were older in each period (p < 0.001). Intracardiac device-associated IE was more frequent in the last decade: pacemaker (5.4 vs. 23% p < 0.0001) and prosthetic valve IE (8.5% vs. 19.2% vs. 47.5% p < 0.0001). On the other hand, IE associated with intravenous drugs (P < 0.0001) and congenital heart diseases (p = 0.001) was significantly less frequent. The etiology changed substantially: Streptococcus viridans group decreased (30.8% vs. 26.8% vs. 15.9%, p < 0.001) and IE by Staphylococcus spp. predominated over other microorganisms, with a statistically significant increase in IE due to coagulase-negative Staphylococcus. Surgical treatment was more frequently implemented in the last decade and was accompanied by a trend towards lower mortality in the CRC (23.5%, 24.3% vs. 17.2% p = 0.058).

La epidemiología de la endocarditis infecciosa (EI) ha sufrido cambios debido a una serie de factores como el envejecimiento, las comorbilidades y los procedimientos médicos. El objetivo de este estudio fue evaluar las principales modificaciones clínicas, epidemiológicas y etiológicas de la EI en los últimos 25 años en Argentina. Se realizó un análisis comparativo de tres registros prospectivos observacionales en los que se incluyeron de forma consecutiva casos de EI definidas y posibles según los criterios de Duke: dos estudios multicéntricos (EIRA-1 [1992-1994] y EIRA-2 [2001-2002]) y un estudio en un centro de referencia de cardiología de tercer nivel (CRC [2007-2017]). En los 1065 episodios de EI evaluados, no existieron diferencias respecto al sexo, y los pacientes fueron más añosos en cada periodo (p < 0.001). La EI asociada a dispositivos intracardiacos fue más frecuente en la última década: infección asociada a marcapasos (5.4 vs. 23% p < 0.0001) y EI de prótesis valvulares (8.5% vs. 19.2% vs. 47.5% p < 0.0001). Por otra parte, la EI asociada a drogas endovenosas (p < 0.0001) y cardiopatías congénitas (p = 0.001) fue significativamente menos frecuente. La etiología cambió sustancialmente: Streptococcus del grupo viridans disminuyó (30.8% vs. 26.8% vs. 15.9%; p < 0.001) y la EI por Staphylococcus spp. predominó por sobre otros microorganismos, con un aumento estadísticamente significativo del Staphylococcus coagulasa negativa (SCN). El tratamiento quirúrgico fue implementado con más frecuencia en la última década y estuvo acompañado de una tendencia a menor mortalidad en el CRC (23.5%, 24.3% vs. 17.2% p = 0.058).

Endocarditis infecciosa en Argentina: ¿qué aprendimos en los últimos 25 años? / Infective endocarditis in Argentina: what have we learned in the last 25 years ?

La epidemiología de la endocarditis infecciosa (EI) ha sufrido cambios debido a una serie de factores como el envejecimiento, las comorbilidades y los procedimientos médicos. El objetivo de este estudio fue evaluar las principales modificaciones clínicas, epidemiológicas y etiológicas de la EI en los últimos 25 años en Argentina. Se realizó un análisis comparativo de tres registros prospectivos observacionales en los que se incluyeron de forma consecutiva casos de EI definidas y posibles según los criterios de Duke: dos estudios multicéntricos (EIRA-1 [1992-1994] y EIRA-2 [2001-2002]) y un estudio en un centro de referencia de cardiología de tercer nivel (CRC [2007-2017]). En los 1065 episodios de EI evaluados, no existieron diferencias respecto al sexo, y los pacientes fueron más añosos en cada periodo (p < 0.001). La EI asociada a dispositivos intracardiacos fue más frecuente en la última década: infección asociada a marcapasos (5.4 vs. 23% p < 0.0001) y EI de prótesis valvulares (8.5% vs. 19.2% vs. 47.5% p < 0.0001). Por otra parte, la EI asociada a drogas endovenosas (p < 0.0001) y cardiopatías congénitas (p = 0.001) fue significativamente menos frecuente. La etiología cambió sustancialmente: Streptococcus del grupo viridans disminuyó (30.8% vs. 26.8% vs. 15.9%; p < 0.001) y la EI por Staphylococcus spp. predominó por sobre otros microorganismos, con un aumento estadísticamente significativo del Staphylococcus coagulasa negativa (SCN). El tratamiento quirúrgico fue implementado con más frecuencia en la última década y estuvo acompañado de una tendencia a menor mortalidad en el CRC (23.5%, 24.3% vs. 17.2% p = 0.058).

The epidemiology of infectious endocarditis (IE) has undergone changes due to a series of factors such as aging, comorbidities and medical procedures. The aim of this study was to evaluate the main clinical, epidemiological and etiological changes of the IE in the last 25 years in Argentina. A comparative analysis of three observational prospective registries was performed in which cases of definite and possible IE were consecutively included according to the Duke criteria: two multicentre studies (EIRA-1 [1992-1994] and EIRA-2 [2001-2002]) and one study in a reference cardiology center (CRC [2007-2017]). In the 1065 episodes of EI evaluated, there were no differences regarding sex, and the patients were older in each period (p < 0.001). Intracardiac device-associated IE was more frequent in the last decade: pacemaker (5.4 vs. 23% p < 0.0001) and prosthetic valve IE (8.5% vs. 19.2% vs. 47.5% p < 0.0001). On the other hand, IE associated with intravenous drugs (P < 0.0001) and congenital heart diseases (p = 0.001) was significantly less frequent. The etiology changed substantially: Streptococcus viridans group decreased (30.8% vs. 26.8% vs. 15.9%, p < 0.001) and IE by Staphylococcus spp. predominated over other microorganisms, with a statistically significant increase in IE due to coagulase-negative Staphylococcus. Surgical treatment was more frequently implemented in the last decade and was accompanied by a trend towards lower mortality in the CRC (23.5%, 24.3% vs. 17.2% p = 0.058).

Endocarditis infecciosa por bacilos gram negativos no HACEK. Experiencia en un centro de alta complejidad de la República Argentina (1998-2016) / Infective endocarditis due to non-HACEK gram-negative bacilli in a Level III cardiovascular center in Argentina (1998-2016)

Los bacilos gram negativos (BGN) que no pertenecen al grupo HACEK son una causa infrecuente de endocarditis infecciosa. Los aspectos epidemiológicos, diagnósticos y pronósticos de esta entidad son poco conocidos y la experiencia aún es limitada. Nuestros objetivos fueron analizar las características clínicas y microbiológicas de las endocarditis infecciosas (EI) por BGN no HACEK diagnosticadas en un centro de alta complejidad de Argentina en el período 1998-2016 y conocer su evolución hospitalaria, a fin de compararlas con las EI debidas a otros microorganismos.

Non-HACEK Gram-negative bacilli are a rare cause of infective endocarditis. Epidemiological, diagnostic and prognostic aspects of this entity are little known, and there is limited experience. The aim of this study was to analyze the clinical, microbiological and in-hospital outcomes of non-HACEK Gram negative bacilli endocarditis and to compare them with those due to other microorganisms.

The association between vegetation size and surgical treatment on 6-month mortality in left-sided infective endocarditis.

AIMS: In left-sided infective endocarditis (IE), a large vegetation >10 mm is associated with higher mortality, yet it is unknown whether surgery during the acute phase opposed to medical therapy is associated with improved survival. We assessed the association between surgery and 6-month mortality as related to vegetation size. METHODS AND RESULTS: Patients with definite, left-sided IE (2008-2012) from The International Collaboration on Endocarditis prospective, multinational registry were included. We compared clinical characteristics and 6-month mortality (by Cox regression with inverse propensity of treatment weighting) between patients with vegetation size ≤10 mm vs. >10 mm in maximum length by surgical treatment strategy. A total of 1006 patients with left sided IE were included; 422 with a vegetation size ≤10 mm (median age 66.0 years, 33% women) and 584 (median age 58.4 years, 34% women) patients with a large vegetation >10 mm. Operative risk by STS-IE score was similar between groups. Embolic events occurred in 28.4% vs. 44.3% (P < 0.001), respectively. Patients with a vegetation >10 mm was associated with higher 6-month mortality (25.1% vs. 19.4% for small vegetation, P = 0.035). However, after propensity adjustment, the association with higher mortality persisted only in patients with a large vegetation >10 mm vs. ≤10 mm: hazard ratio (HR) 1.55 (1.27-1.90); but only in patients with large vegetation managed medically [HR 1.86 (1.48-2.34)] rather than surgically [HR 1.01 (0.69-1.49)]. CONCLUSION: Left-sided IE with vegetation size >10 mm was associated with an increased mortality at 6 months in this observational study but was dependent on treatment strategy. For patients with large vegetation undergoing surgical treatment, survival was similar to patients with smaller vegetation size.

Association between the timing of surgery for complicated, left-sided infective endocarditis and survival.

BACKGROUND: In patients with active infective endocarditis (IE), the relationship between timing of surgery and survival is uncertain. The objective was to evaluate clinical characteristics associated with timing of surgery and the association between surgical timing and 6-month survival in complicated, left-sided IE. METHODS: In a prospective, multicenter, observational registry (The International Collaboration on Endocarditis-PLUS, registry from 2008 to 2012), clinical factors associated with timing of surgery during the index hospitalization were determined among 485 adult patients with definite, complicated, left-sided IE who underwent cardiac surgery during their index hospitalization. The relationship between early surgical intervention (<7 days from admission to surgery center) and outcome after surgery was analyzed. The primary end point of the study was 6-month survival. RESULTS: The median time to surgery from admission to surgical center was 7 (interquartile range 2-15) days. Patients who underwent earlier surgery were more likely transferred to the surgical center (74.2% vs 46.4%, P < .001) and had a lower percentage of preexisting heart failure (before IE diagnosis) (6.0% vs 17.3%, P < .001) but higher rate of acute heart failure (53.2% vs 38.4%, P = .001). Variables independently associated with surgery <7 days from admission were patient transfer, acute heart failure, and nonelective surgical status (C-index = 0.84), but predicted operative risk was not. Cox proportional hazards modeling with inverse probability of treatment weighting found that earlier surgery was associated with a trend toward higher 6-month mortality compared with later surgery (hazard ratio = 1.68, 95% CI 0.97-2.96; P = .065), particularly surgery within 2 days of admission or transfer. Mortality was significantly associated with operative risk and complicated IE, including Staphylococcus aureus infection and presence of abscess. CONCLUSIONS: Earlier surgery in IE is strongly associated with acute heart failure and surgical urgency. After adjustment for operative risk and IE complications, earlier surgery <7 days from admission was associated with a trend toward higher 6-month overall mortality compared with surgery later in the index hospitalization.

[Infective endocarditis due to non-HACEK gram-negative bacilli in a Level III cardiovascular center in Argentina (1998-2016)]. / Endocarditis infecciosa por bacilos gram negativos no HACEK. Experiencia en un centro de alta complejidad de la República Argentina (1998-2016).

Non-HACEK Gram-negative bacilli are a rare cause of infective endocarditis. Epidemiological, diagnostic and prognostic aspects of this entity are little known, and there is limited experience. The aim of this study was to analyze the clinical, microbiological and in-hospital outcomes of non-HACEK Gram negative bacilli endocarditis and to compare them with those due to other microorganisms.

Infective endocarditis in argentina. results of the eira 3 Study / Endocarditis infecciosa en la República Argentina. Resultados del estudio EIRA 3

ABSTRACT: Background: The clinical and epidemiological characteristics of infective endocarditis (IE), a complex disease with high morbidity and mortality, have changed over time. Our country lacks updated information since the publication of the EIRA 1 and 2 studies (1992 and 2002). Objective: The aim of this study was to analyze the epidemiology, clinical and microbiological characteristics and hospital outcome of patients with IE. Methods: A prospective multicenter observational study of patients with definite IE was conducted according to the modified Duke criteria. results: A total of 502 patients were recruited from 48 centers (69.5% in the Buenos Aires Metropolitan Area). Mean age 60.7±19.3 years and 69.9% (n=351) were men]; 54.64% of patients (n=274) did not present underlying heart disease, 19.9% (n=100) had pros-thetic valves and 38.1% (n=191) had history of a healthcare-related procedure. The diagnosis was made within one month after the first clinical manifestation in 73.3% of cases (n=368) [76.5% (n=384) in the native valve]. The aortic valve was the most commonly affected valve (45.96%; n=230), followed by mitral valve involvement (33%; n=150). The most common germs were Staphylococcus spp in 46.3% of patients (n=232), Streptococcus spp in 28.2% (n=141) and Enterococcus in 12.8% (n=64). Blood cultures were nega-tive in 44 patients (8.76%). Complications: heart failure (30.9%; n=155), peripheral embolism (19.6%; n=98) and abscess (15.5%; n=78). Adequate empirical antibiotic treatment was administered to 62.4% (n=313) of the patients and 43.6% (n=219) underwent surgical treatment. Overall in-hospital mortality was 25.5% (n=128). Age, history of chronic kidney failure, mitral valve disease and heart failure were independent predictors of in-hospital mortality. Conclusions: A high percentage of patients with IE do not present known prior heart disease. Staphylococcus spp was the most com-mon microorganism. Mortality remains high and similar to the one observed in the EIRA 1 and 2 studies.

RESUMEN: introducción: La endocarditis infecciosa (EI) es una enfermedad compleja con elevada morbimortalidad, cuyas características clínicas y epidemiológicas han variado. Desde la realización de los Estudios EIRA 1 y 2 (1992 y 2002) no se dispone de información nacional actualizada. Objetivo: Analizar la epidemiología, características clínicas, microbiológicas y evolución hospitalaria de los pacientes con EI. Material y Métodos: Estudio observacional prospectivo multicéntrico de EI definidas según los criterios de Duke modificados. resultados: En 48 centros, (69.5% Área Metropolitana Buenos Aires), se registraron 502 pacientes; edad 60,7 ± 19,3 años, hombres 69,9% (N=351). El 54,64% de los pacientes (N= 274) no presentó cardiopatía subyacente. El 38,1% (N=191) tenía antecedentes de un procedimiento asociado al cuidado de la salud. En el 73,3% (N=368) se realizó el diagnóstico dentro del mes de la primera manifestación clínica. La localización más frecuente fue la aórtica, tanto en EI por válvulas nativas como protésicas (48,24%/N=233) seguida de mitral (25,88%/N=125). Los gérmenes más frecuentes fueron: Staphylococcus spp 46,3% (N=210), Streptococcus spp 28,2% (N=128) y Enterococcus spp 12,8% (N=58). En 9,56% (N=48) de los casos los hemocul-tivos fueron negativos. Complicaciones: insuficiencia cardíaca (30,9%/N=155), embolias periféricas (19,6%/N=98) y absceso (15,5%/ N=78). El 62,4% (N= 313) recibió tratamiento antibiótico empírico adecuado y el 43,4% tratamiento quirúrgico (N= 218). Mortalidad hospitalaria global: 25,5% (N=128). La edad, el antecedente de insuficiencia renal, la afección de la válvula mitral y la presencia de insuficiencia cardíaca fueron predictores de mortalidad hospitalaria. Conclusiones: Existe un elevado porcentaje de pacientes con EI sin enfermedad cardíaca previa conocida. El Staphylococcus spp fue el germen causal más frecuente. La mortalidad se mantiene elevada, y similar a la de los estudios EIRA 1 y 2.

[Recommendations for prevention of surgical site infection in adult elective arthroplasty]. / Recomendaciones para la prevención de infecciones asociadas a artoplastia electiva en adultos.

Surgical site infections complicating orthopedic implant surgeries prolong hospital stay and increase risk of readmission, hospitalization costs and mortality. These recommendations are aimed at: (i) optimizing compliance and incorporating habits in all surgery phases by detecting risk factors for surgical site infections which are potentially correctable or modifiable; and (ii) optimizing preoperative antibiotic prophylaxis as well as intraoperative and postoperative care.

Estrategia de control de la resistencia bacteriana a los antimicrobianos en Argentina / Strategy for controlling bacterial resistance to antimicrobial drugs in Argentina / Estratégia de controle da resistência bacteriana aos antimicrobianos na Argentina

La aceleración observada en las últimas décadas sobre la emergencia y diseminación de la resistencia a los antimicrobianos está vinculada al abuso y/o mal uso de los antimicrobianos. En 2014, el Ministerio de Salud de Argentina, junto a otros organismos e instituciones, implementó una estrategia nacional para el control de la resistencia a los antimicrobianos con el objetivo de retrasar o impedir la emergencia y diseminación de bacterias resistentes. Este trabajo describe las acciones propuestas y los resultados obtenidos durante el primer período de implementación en materia de fortalecimiento de la vigilancia en salud humana, creación de una red de vigilancia en salud animal, planificación de la vigilancia del consumo de antimicrobianos, fiscalización de restricciones en la venta de estos, adecuación de las formas farmacéuticas a las necesidades de tratamiento, actualización del registro de antimicrobianos y de métodos de diagnóstico, restricción de su uso como promotores de crecimiento, promoción de su uso responsable, elaboración de guías de diagnóstico y tratamiento, creación de programas de gestión de antimicrobianos, y fortalecimiento de los programas de prevención y control de infecciones en establecimientos de salud y de producción agropecuaria. Muchas de estas medidas son de implementación inmediata, particularmente en materia de regulación, fiscalización y gestión de antimicrobianos, y pueden reducir su uso innecesario y con ello el impacto sobre la resistencia a los antimicrobianos.

The accelerated emergence and spread of antimicrobial resistance observed in recent decades is associated with the abuse and/or misuse of antimicrobial drugs. In 2014, Argentina’s Ministry of Health, in conjunction with other agencies and institutions, rolled out a national antimicrobial resistance control strategy designed to slow or prevent the emergence and spread of resistant bacteria. This article describes the action proposed and results obtained during the first implementation period in terms of improving human health surveillance, creating an animal health surveillance network, planning antimicrobial drugs consumption surveillance, monitoring restrictions on sales, adapting dosage forms to treatment needs, updating the antimicrobial drugs registry and diagnostic methods, restricting the use of these drugs as growth promoters, encouraging responsible use, preparing diagnostic and treatment guidelines, creating antimicrobial drugs management programs, and strengthening infection prevention and control programs in health facilities and livestock production. Many of these measures, particularly those related to antimicrobial drugs regulation, control, and management, can be implemented immediately, reducing the unnecessary use of these products, and with it, the impact on antimicrobial resistance.

O aceleramento observado nas últimas décadas no surgimento e na disseminação da resistência aos antimicrobianos está vinculado ao uso excessivo e/ou mau uso dos antimicrobianos. Em 2014, o Ministério da Saúde da Argentina, junto com outros órgãos e instituições, implementou uma estratégia nacional para o controle da resistência aos antimicrobianos com o objetivo de retardar ou impedir o surgimento e disseminação de bactérias resistentes. Este estudo descreve as ações propostas e os resultados obtidos no primeiro período de implementação no que se refere ao reforço da vigilância em saúde humana, criação de uma rede de vigilância em saúde animal, planejamento da vigilância do uso de antimicrobianos, fiscalização das restrições na venda de antimicrobianos, adequação das formas farmacêuticas à necessidade de tratamento, atualização do registro de antimicrobianos e de métodos diagnósticos, restrição do uso de antimicrobianos como promotores de crescimento, incentivo ao uso responsável dos antimicrobianos, elaboração de guias de diagnóstico e tratamento, criação de programas de controle de antimicrobianos e fortalecimento dos programas de prevenção e controle de infecções em estabelecimentos de assistência à saúde e de atividade agropecuária. Muitas das medidas são de implementação imediata, em particular a regulamentação, fiscalização e controle dos antimicrobianos, e podem reduzir o uso desnecessário e consequentemente o impacto na resistência aos antimicrobianos.