RESUMO
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
RESUMO
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)
Assuntos
Humanos , Adulto , Infecções Relacionadas a Cateter , Cateteres de Demora , Cateterismo Periférico/efeitos adversos , Infecção Hospitalar/transmissão , BacteriemiaRESUMO
Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) for the identification of nontuberculous mycobacterial (NTM) isolates was evaluated in this study. Overall, 125 NTM isolates were analyzed by MALDI-TOF and GenoType CM/AS. Identification by 16S rRNA/hsp65 sequencing was considered the gold standard. Agreements between MALDI-TOF and GenoType CM/AS with the reference method were, respectively, 94.4% and 84.0%. In 17 cases (13.6%), results provided by GenoType and MALDI-TOF were discordant; however, the reference method agreed with MALDI-TOF in 16/17 cases (94.1%; P = 0.002).
Assuntos
Técnicas Bacteriológicas/métodos , Infecções por Mycobacterium não Tuberculosas/diagnóstico , Micobactérias não Tuberculosas/isolamento & purificação , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz/métodos , Proteínas de Bactérias/genética , Chaperonina 60/genética , Análise por Conglomerados , DNA Bacteriano/química , DNA Bacteriano/genética , DNA Ribossômico/química , DNA Ribossômico/genética , Técnicas de Genotipagem/métodos , Dados de Sequência Molecular , Infecções por Mycobacterium não Tuberculosas/microbiologia , Micobactérias não Tuberculosas/química , Filogenia , RNA Ribossômico 16S/genética , Análise de Sequência de DNARESUMO
BACKGROUND: Frequency of enterococcal bloodstream infection (E-BSI) is increasing, and the number of episodes complicated by infective endocarditis (IE) varies. Performing transesophageal echocardiography (TEE) in all patients with E-BSI is costly and time-consuming. Our objectives were to identify patients with E-BSI who are at very low risk of enterococcal IE (and therefore do not require TEE) and to compare the outcome of E-BSI in patients with/without IE. METHODS: Between September 2003 and October 2012, we performed a prospective cohort study (all patients with E-BSI) and a case-control study (patients with/without enterococcal IE) in our center. RESULTS: We detected 1515 patients with E-BSI and 65 with enterococcal IE (4.29% of all episodes of E-BSI, 16.7% of patients with E-BSI who underwent transthoracic echocardiography, and 35.5% of all patients with E-BSI who underwent TEE). We developed a bedside predictive score for enterococcal IE-Number of positive blood cultures, Origin of the bacteremia, previous Valve disease, Auscultation of heart murmur (NOVA) score-based on the following variables: Number of positive blood cultures (3/3 blood cultures or the majority if more than 3), 5 points; unknown Origin of bacteremia, 4 points; prior heart Valve disease, 2 points; Auscultation of a heart murmur, 1 point (receiver operating characteristic = 0.83). The best cutoff corresponded to a score ≥4 (sensitivity, 100%; specificity, 29%). A score <4 points suggested a very low risk for enterococcal IE and that TEE could be obviated. CONCLUSIONS: Enterococcal IE may be more frequent than generally thought. Depending on local prevalence of endocarditis, application of the NOVA score may safely obviate echocardiography in 14%-27% of patients with E-BSI.
Assuntos
Bacteriemia/complicações , Ecocardiografia Transesofagiana , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/epidemiologia , Enterococcus faecalis/isolamento & purificação , Enterococcus , Infecções por Bactérias Gram-Positivas/diagnóstico , Adolescente , Adulto , Idoso , Sangue/microbiologia , Estudos de Casos e Controles , Estudos de Coortes , Ecocardiografia Transesofagiana/estatística & dados numéricos , Endocardite Bacteriana/diagnóstico por imagem , Enterococcus/isolamento & purificação , Feminino , Infecções por Bactérias Gram-Positivas/diagnóstico por imagem , Infecções por Bactérias Gram-Positivas/epidemiologia , Sopros Cardíacos , Doenças das Valvas Cardíacas , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Espanha , Adulto JovemRESUMO
BACKGROUND: Patients with septic episodes whose blood cultures turn positive after being sent home from emergency departments (EDs) are recognized as having occult bloodstream infections (BSI). The incidence, etiology, clinical circumstances, and outcome of occult BSI in children are well known, but, to our knowledge, data in adult patients are scarce. We analyzed the episodes of occult BSI in adult patients at our institution. METHODS: This is a retrospective cohort study (September 2010 to September 2012), in adult patients discharged from the ED in whom blood cultures turned positive. Patients were evaluated according to a preestablished protocol. RESULTS: We recorded 4025 cases of significant BSI in the ED and 113 patients with adult occult BSI. In other words, the incidence of occult BSI in the ED was 2.8 per 100 episodes. The predominant microorganisms were gram-negative bacteria (57%); Escherichia coli was the most common (41%), followed by gram-positive bacteria (29%), anaerobes (6.9%), polymicrobial (6.1%), and yeasts (0.8%). The most frequent suspected origin was urinary tract infection (53%), and most infections were community acquired (63.7%). Of the 105 patients that we were able to trace, 54 (42.5%) were asymptomatic and were receiving adequate antibiotic treatment at the time of the call, and 65 (51.2%) had persistent fever or were not receiving adequate antibiotic treatment. CONCLUSIONS: Occult BSI is relatively common in patients in the adult ED. Despite the need for readmission of a fairly high proportion of patients, occult BSI behaves as a relatively benign entity.
Assuntos
Bacteriemia/diagnóstico , Adulto , Idoso , Bacteriemia/epidemiologia , Bacteriemia/microbiologia , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/microbiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Infecções por Bactérias Gram-Negativas/diagnóstico , Infecções por Bactérias Gram-Negativas/epidemiologia , Infecções por Bactérias Gram-Negativas/microbiologia , Infecções por Bactérias Gram-Positivas/diagnóstico , Infecções por Bactérias Gram-Positivas/epidemiologia , Infecções por Bactérias Gram-Positivas/microbiologia , Hospitais de Ensino/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Estudos RetrospectivosRESUMO
INTRODUCTION: The use of the matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) mass spectrometry has shown to be effective and fast in some clinical specimens for the identification of colonizing microorganisms. The objective of the study was to analyze the validity values for the prediction of colonization and catheter-related bloodstream infection (C-RBSI) of the MALDI-TOF mass spectrometry performed at all intravascular catheters that arrived in the microbiology laboratory. Methods Catheter tips (after performing the roll-plate technique) were tested by MALDI-TOF mass spectrometry during a period of 3-months. The gold standard for colonization and C-RBSI were, respectively: the presence of ≥ 15 cfu/plate in the catheter tip culture; and the isolation of the same microorganism(s) in blood cultures as well as in the colonized catheter (during the 7 days before or after catheter withdrawal).Results A total of 182 intravascular catheters were collected. The overall colonization rate detected by roll-plate technique and MAL-TOF mass spectrometry was 31.9% and 32.4%, respectively. Overall, there were 33 (18.1%) episodes of C-RBSI. The validity values of the MALDI-TOF mass spectrometry for the identification of colonization and C-RBSI were, respectively: sensitivity (69.0%/66.7%), specificity (84.7%/75.2%), positive predictive value (65.6%/36.1%), and negative predictive value (86.8%/92.6%). Conclusion MALDI-TOF mass spectrometry could be an alternative diagnostic tool for ruling out C-RBSI. However, despite it showing to be faster than conventional culture, future studies are required in order to improve the pre-analytical process
INTRODUCCIÓN: La espectrometría de masas MALDI-TOF ha demostrado ser rápida y eficaz en la identificación de microorganismos que colonizan determinadas muestras clínicas. Nuestro objetivo fue analizarlos valores de validez de la espectrometría de masas MALDI-TOF para predecir colonización y bacteriemia relacionada con el catéter (BRC) en todos los catéteres que llegaran al laboratorio de Microbiología. MÉTODOS: Durante 3 meses, la espectrometría de masas MALDI-TOF se realizó sobre las puntas de catéter recibidas (previo rodamiento para cultivo). Las reglas de oro de colonización y BRC fueron, respectivamente, la presencia de ≥ 15 ufc/placa en el cultivo de la punta de catéter y el aislamiento del (de los)mismo(s) microorganismo(s) tanto en los hemocultivos como en el catéter colonizado (7 días antes o después de la retirada del catéter). RESULTADOS: Se incluyeron un total de 182 catéteres intravasculares. La tasa global de colonización detectada por la técnica del rodamiento y la espectrometría de masas MALDI-TOF fue del 31,9 y del 32,4%, respectivamente. Hubo un total de 33 (18,1%) episodios de BRC. Los valores de validez de la espectrometría de masas MALDI-TOF para predecir colonización y BRC fueron, respectivamente: sensibilidad (69,0/66,7%), especificidad (84,7/75,2%), valor predictivo positivo (65,6/36,1%) y valor predictivo negativo (86,8/92,6%). CONCLUSIÓN: La espectrometría de masas MALDI-TOF puede ser una herramienta de diagnóstico alternativa para descartar BRC. Sin embargo, a pesar de haber demostrado ser más rápida que el cultivo convencional, son necesarios futuros estudios que mejoren el proceso pre-analítico
Assuntos
Humanos , Cateterismo/métodos , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Cateteres de Demora/microbiologia , Infecções Relacionadas a Cateter/microbiologia , Biofilmes/crescimento & desenvolvimento , Bacteriemia/microbiologiaRESUMO
UNLABELLED: It was our purpose to evaluate the clinical impact of systematic PET/CT for the diagnosis of infectious embolisms in patients with infectious endocarditis (IE) in comparison with a historic cohort of IE patients managed without this technique. Detection of extracardiac lesions is an essential component of the management and outcome of IE. Studies using PET/CT for the evaluation of patients with IE are scarce, lack a control group, evaluate a small number of patients, or consist of case reports. METHODS: We performed a prospective cohort study (47 patients with definite IE undergoing PET/CT) with matched controls (94 patients with definite IE not undergoing PET/CT) from January 2012 to July 2013 in a tertiary hospital. The results were compared with those of conventional diagnostic techniques and clinical follow-up. RESULTS: PET/CT revealed at least 1 lesion in 35 patients (74.5%): 18 showed an embolic complication, 8 showed pathologic uptake on the valves or cardiac devices, 1 showed both, 5 had incidental noninfectious findings, and the findings for 3 were considered false-positive. The validity values for the efficacy of PET/CT in the diagnosis of septic lesions were as follows: sensitivity, 100%; specificity, 80%; positive predictive value, 90%; and negative predictive value, 100%. PET/CT was the only initially positive imaging technique in 15 true-positive cases (55.5%). The systematic use of PET/CT was associated with a 2-fold reduction in the number of relapses (9.6% vs. 4.2%, P = 0.25) and enabled significantly more infectious complications to be diagnosed (18% vs. 57.4%, P = 0.0001). CONCLUSION: PET/CT enables the extent of IE to be assessed using a single test. It is fast (<2 h) and comfortable for the patient, gathers whole-body data, and detects significantly more infectious complications.
Assuntos
Endocardite/complicações , Endocardite/diagnóstico por imagem , Fluordesoxiglucose F18 , Tomografia por Emissão de Pósitrons , Sepse/complicações , Estudos de Casos e Controles , Estudos de Coortes , Embolia/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: The use of the matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) mass spectrometry has shown to be effective and fast in some clinical specimens for the identification of colonizing microorganisms. The objective of the study was to analyze the validity values for the prediction of colonization and catheter-related bloodstream infection (C-RBSI) of the MALDI-TOF mass spectrometry performed at all intravascular catheters that arrived in the microbiology laboratory. METHODS: Catheter tips (after performing the roll-plate technique) were tested by MALDI-TOF mass spectrometry during a period of 3-months. The gold standard for colonization and C-RBSI were, respectively: the presence of ≥15cfu/plate in the catheter tip culture; and the isolation of the same microorganism(s) in blood cultures as well as in the colonized catheter (during the 7days before or after catheter withdrawal). RESULTS: A total of 182 intravascular catheters were collected. The overall colonization rate detected by roll-plate technique and MAL-TOF mass spectrometry was 31.9% and 32.4%, respectively. Overall, there were 33 (18.1%) episodes of C-RBSI. The validity values of the MALDI-TOF mass spectrometry for the identification of colonization and C-RBSI were, respectively: sensitivity (69.0%/66.7%), specificity (84.7%/75.2%), positive predictive value (65.6%/36.1%), and negative predictive value (86.8%/92.6%). Conclusion MALDI-TOF mass spectrometry could be an alternative diagnostic tool for ruling out C-RBSI. However, despite it showing to be faster than conventional culture, future studies are required in order to improve the pre-analytical process.
Assuntos
Infecções Relacionadas a Cateter/microbiologia , Contaminação de Equipamentos/prevenção & controle , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Dispositivos de Acesso Vascular/microbiologia , Humanos , Valor Preditivo dos TestesRESUMO
This study evaluates matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) capability for the identification of difficult-to-identify microorganisms. A total of 150 bacterial isolates inconclusively identified with conventional phenotypic tests were further assessed by 16S rRNA sequencing and by MALDI-TOF MS following 2 methods: a) a simplified formic acid-based, on-plate extraction and b) performing a tube-based extraction step. Using the simplified method, 29 isolates could not be identified. For the remaining 121 isolates (80.7%), we obtained a reliable identification by MALDI-TOF: in 103 isolates, the identification by 16S rRNA sequencing and MALDI TOF coincided at the species level (68.7% from the total 150 analyzed isolates and 85.1% from the samples with MALDI-TOF result), and in 18 isolates, the identification by both methods coincided at the genus level (12% from the total and 14.9% from the samples with MALDI-TOF results). No discordant results were observed. The performance of the tube-based extraction step allowed the identification at the species level of 6 of the 29 unidentified isolates by the simplified method. In summary, MALDI-TOF can be used for the rapid identification of many bacterial isolates inconclusively identified by conventional methods.
Assuntos
Bactérias/isolamento & purificação , Tipagem Molecular/métodos , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz/métodos , Fluxo de Trabalho , Bactérias/genética , Infecções Bacterianas/microbiologia , Bacteriologia , DNA Bacteriano/genética , Humanos , Laboratórios/organização & administração , RNA Ribossômico 16S/genéticaRESUMO
Microbiological confirmation of a urinary tract infection (UTI) takes 24-48 h. In the meantime, patients are usually given empirical antibiotics, sometimes inappropriately. We assessed the feasibility of sequentially performing a Gram stain and MALDI-TOF MS mass spectrometry (MS) on urine samples to anticipate clinically useful information. In May-June 2012, we randomly selected 1000 urine samples from patients with suspected UTI. All were Gram stained and those yielding bacteria of a single morphotype were processed for MALDI-TOF MS. Our sequential algorithm was correlated with the standard semiquantitative urine culture result as follows: Match, the information provided was anticipative of culture result; Minor error, the information provided was partially anticipative of culture result; Major error, the information provided was incorrect, potentially leading to inappropriate changes in antimicrobial therapy. A positive culture was obtained in 242/1000 samples. The Gram stain revealed a single morphotype in 207 samples, which were subjected to MALDI-TOF MS. The diagnostic performance of the Gram stain was: sensitivity (Se) 81.3%, specificity (Sp) 93.2%, positive predictive value (PPV) 81.3%, negative predictive value (NPV) 93.2%, positive likelihood ratio (+LR) 11.91, negative likelihood ratio (-LR) 0.20 and accuracy 90.0% while that of MALDI-TOF MS was: Se 79.2%, Sp 73.5, +LR 2.99, -LR 0.28 and accuracy 78.3%. The use of both techniques provided information anticipative of the culture result in 82.7% of cases, information with minor errors in 13.4% and information with major errors in 3.9%. Results were available within 1 h. Our serial algorithm provided information that was consistent or showed minor errors for 96.1% of urine samples from patients with suspected UTI. The clinical impacts of this rapid UTI diagnosis strategy need to be assessed through indicators of adequacy of treatment such as a reduced time to appropriate empirical treatment or earlier withdrawal of unnecessary antibiotics.
Assuntos
Algoritmos , Violeta Genciana , Fenazinas , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz/métodos , Infecções Urinárias/diagnóstico , Urina/microbiologia , Humanos , Funções Verossimilhança , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Infecções Urinárias/microbiologiaRESUMO
We retrospectively studied 22 patients with catheter-related candidemia caused by Candida albicans. Strains isolated simultaneously from blood and catheter tips were genotyped using six microsatellite markers. Matches between genotypes of isolates recovered from both sample sources were found in 20/22 (91%) patients. Consequently, identification of the same species from both the catheter tip and blood could be used to confirm catheter-related candidemia.
Assuntos
Candida albicans/isolamento & purificação , Candidemia/diagnóstico , Candidemia/microbiologia , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/microbiologia , Tipagem Molecular/métodos , Técnicas de Tipagem Micológica/métodos , Adulto , Sangue/microbiologia , Cateteres/microbiologia , Feminino , Genótipo , Humanos , Recém-Nascido , Masculino , Repetições de Microssatélites , Epidemiologia Molecular/métodos , Estudos RetrospectivosRESUMO
Genotyping of Candida albicans strains causing candidemia can uncover the presence of endemic genotypes in the hospital. Using a highly reproducible and discriminatory microsatellite marker panel, we studied the genetic diversity of 217 C. albicans isolates from the blood cultures of 202 patients with candidemia (from January 2007 to December 2011). Each isolate represented 1 candidemia episode. Multiple episodes were defined as the isolation of C. albicans in further blood cultures taken ≥7 days after the last isolation in blood culture. Of the 202 patients, 188 had 1 episode, 13 had 2 episodes, and 1 had 3 episodes. Identical genotypes showed the same alleles for all 6 markers. The genotypes causing both episodes were identical in most patients with 2 episodes (11/13; 84.6%). In contrast, 2 different genotypes were found in the patient with 3 episodes, one causing the first and second episodes and the other causing the third episode (isolated 6 months later). We found marked genetic diversity in 174 different genotypes: 155 were unique, and 19 were endemic and formed 19 clusters (2 to 6 patients per cluster). Up to 25% of the patients were infected by endemic genotypes that infected 2 or more different patients. Some of these endemic genotypes were found in the same unit of the hospital, mainly neonatology, whereas others infected patients in different wards.
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Candida albicans/classificação , Candida albicans/genética , Candidemia/epidemiologia , Candidemia/microbiologia , Variação Genética , Hospitais , Adolescente , Adulto , Candida albicans/isolamento & purificação , Criança , Pré-Escolar , Feminino , Genótipo , Humanos , Lactente , Recém-Nascido , Masculino , Repetições de Microssatélites , Epidemiologia Molecular , Tipagem Molecular , Técnicas de Tipagem MicológicaRESUMO
OBJECTIVES: Polymicrobial bloodstream infection (BSI) is an imprecisely defined entity purportedly associated with a worse outcome than monomicrobial BSI. This study examines trends in BSI episodes caused by bacteria and Candida spp. (mixed-BSI) in a large teaching hospital. METHODS: All episodes of BSI from January 2000 to December 2010 were reviewed. Three groups (nâ=â54 each) of patients were compared: all adults with mixed-BSI from January 2006 to December 2010 (cases) and randomly selected patients with polybacterial BSI (polyB-BSI) (Control 1) or Candida spp. BSI (Candida-BSI) (Control 2) in this same period. RESULTS: A total of 139 episodes of mixed-BSI were recorded (0.7% of all BSI, 6.9% of all poly-BSI and 18.0% of all Candida-BSI episodes). The incidence of mixed-BSI was 0.21 cases/1000 admissions, increasing from 0.08 (2000) to 0.34 (2010) cases/1000 admissions (Pâ=â0.007). Mixed-BSI represented 11.8% and 22.9% of all episodes of candidaemia in 2000 and 2010, respectively (Pâ=â0.011). Compared with polyB-BSI, mixed-BSI patients showed fewer malignancies, more frequent nosocomial or intravenous catheter BSI source and less frequent intra-abdominal origin, were more frequently admitted to an intensive care unit (ICU), received more antimicrobials and showed a longer hospital stay and higher mortality. Compared with Candida-BSI, mixed-BSI patients showed more severe underlying diseases, were more frequently admitted to an ICU or oncology-haematology unit, showed a higher APACHE II score, more often progressed to septic shock or multiorgan failure and received more antimicrobials. Mortality was similar. CONCLUSIONS: Mixed-BSI is a rare, distinct infection with a worse prognosis than polyB-BSI. We were unable to detect differences in the prognosis of mixed-BSI when compared with Candida-BSI.
Assuntos
Bacteriemia/complicações , Bacteriemia/epidemiologia , Candidemia/complicações , Candidemia/epidemiologia , Coinfecção/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Hospitais de Ensino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Análise de SobrevidaRESUMO
Management of complicated bloodstream infections requires more aggressive treatment than uncomplicated bloodstream infections. We assessed the value of follow-up blood culture in bloodstream infections caused by Staphylococcus aureus, Enterococcus spp., Streptococcus spp., and Candida spp. and studied the value of persistence of DNA in blood (using SeptiFast) for predicting complicated bloodstream infections. Patients with bloodstream infections caused by these microorganisms were enrolled prospectively. After the first positive blood culture, samples were obtained every third day to perform blood culture and SeptiFast analyses simultaneously. Patients were followed to detect complicated bloodstream infection. The study sample comprised 119 patients. One-third of the patients developed complicated bloodstream infections. The values of persistently positive tests to predict complicated bloodstream infections were as follows: SeptiFast positive samples (sensitivity, 56%; specificity, 79.5%; positive predictive value, 54%; negative predictive value, 80.5%; accuracy, 72.3%) and positive blood cultures (sensitivity, 30.5%; specificity, 92.8%; positive predictive value, 64%; negative predictive value, 75.5%; accuracy, 73.9%). Multivariate analysis showed that patients with a positive SeptiFast result between days 3 and 7 had an almost 8-fold-higher risk of developing a complicated bloodstream infection. In S. aureus, the combination of both techniques to exclude endovascular complications was significantly better than the use of blood culture alone. We obtained a score with variables selected by the multivariate model. With a cutoff of 7, the negative predictive value for complicated bloodstream infection was 96.6%. Patients with a positive SeptiFast result between days 3 and 7 after a positive blood culture have an almost 8-fold-higher risk of developing complicated bloodstream infections. A score combining clinical data with the SeptiFast result may improve the exclusion of complicated bloodstream infections.
Assuntos
Bacteriemia/diagnóstico , Candida/isolamento & purificação , Candidemia/diagnóstico , Bactérias Gram-Positivas/isolamento & purificação , Infecções por Bactérias Gram-Positivas/diagnóstico , Técnicas de Diagnóstico Molecular/métodos , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/microbiologia , Sangue/microbiologia , Candida/classificação , Candida/genética , Candidemia/microbiologia , DNA Bacteriano/sangue , DNA Bacteriano/genética , DNA Fúngico/sangue , DNA Fúngico/genética , Feminino , Bactérias Gram-Positivas/classificação , Bactérias Gram-Positivas/genética , Infecções por Bactérias Gram-Positivas/microbiologia , Humanos , Masculino , Técnicas Microbiológicas/métodos , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeAssuntos
Aspergillus/isolamento & purificação , Sangue/microbiologia , Aspergilose Pulmonar Invasiva/diagnóstico , Doença Pulmonar Obstrutiva Crônica/complicações , Idoso , Evolução Fatal , Humanos , Imunossupressores/uso terapêutico , Pulmão/diagnóstico por imagem , Pulmão/patologia , Masculino , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Radiografia , Esteroides/uso terapêuticoRESUMO
BACKGROUND: Recent studies have reported a greater probability of vancomycin treatment failure in methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections caused by strains with a vancomycin MIC ≥ 1.5 mg/L. However, previous reports included patients treated without adjustments based on vancomycin serum levels and with different methods to evaluate MICs, which may render different results. METHODS: Over a 5 year period (2005-09), vancomycin MICs were determined for 361 MRSA isolates recovered from 309 patients with bloodstream infection using microdilution and the Etest simultaneously. The relationship between the vancomycin MICs determined by each method was assessed. To assess the outcome of patients treated with vancomycin, 104 patients for whom serum vancomycin levels had been determined were selected. RESULTS: The percentage of MRSA strains with MIC values ≥ 1.5 mg/L according to the Etest was 66.5% compared with only 3.6% according to microdilution. No correlation between mortality and any MIC value obtained with either method was observed, independently of the vancomycin serum levels measured. CONCLUSIONS: There is a poor correlation between vancomycin MIC values obtained by microdilution and by Etest. No association between mortality rate and any MIC value was observed, not even in patients with suboptimal vancomycin trough serum levels. These data do not support replacing or complementing the standard microdilution test with the Etest for determination of MICs of vancomycin in microbiology laboratories.
Assuntos
Antibacterianos/farmacologia , Bacteriemia/tratamento farmacológico , Bacteriemia/microbiologia , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Infecções Estafilocócicas/tratamento farmacológico , Infecções Estafilocócicas/microbiologia , Vancomicina/farmacologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/mortalidade , Feminino , Humanos , Masculino , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Testes de Sensibilidade Microbiana/métodos , Pessoa de Meia-Idade , Prognóstico , Infecções Estafilocócicas/mortalidade , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVES: To analyze the incidence trend of listeriosis, its present epidemiology and the potential benefit of aminoglycosides during the last two decades. METHODS: We reviewed all cases of invasive listeriosis detected during a 22-year period in a large tertiary hospital. Two equal periods of 11 years were compared. RESULTS: We detected 111 cases of listeriosis (32 during the first 11-year period and 79 during the second). Incidence of listeriosis increased significantly (from 4.66/10(6) inhabitants to 10.39/10(6) inhabitants; P = .001). In the second period, there were more patients >65 years (21.9%-45.6%; P = .02) and with no significant underlying diseases (0 vs. 16.5%; P = .02). Comparing clinical presentations between the two periods, primary bacteremia increased (40.6% vs. 55.7%), while central nervous system infections decreased (34.4% vs. 27.8%). Cotrimoxazole (SXT) use increased significantly in the second period (from 6.3% to 40.5%, P = .001) while the administration of aminoglycosides decreased (from 40.6% to 21.5%, P = .04). The use of combination therapy did not have any impact on mortality, however it did increase toxicity. CONCLUSIONS: Listeriosis should be considered an emerging health problem, especially among the elderly, including those with no underlying medical conditions. The use of aminoglycosides does not seem to be justified according to our data.
Assuntos
Doenças Transmissíveis Emergentes/epidemiologia , Listeriose/epidemiologia , Adulto , Fatores Etários , Idoso , Aminoglicosídeos/uso terapêutico , Antibacterianos/uso terapêutico , Doenças Transmissíveis Emergentes/tratamento farmacológico , Doenças Transmissíveis Emergentes/patologia , Feminino , Hospitais , Humanos , Incidência , Listeriose/tratamento farmacológico , Listeriose/patologia , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Campylobacter is a very rare cause of bloodstream infection, although it has been found relatively frequently in patients infected with human immunodeficiency virus (HIV). The impact of highly active antiretroviral therapy (HAART) and new forms of immunosuppression on the incidence of Campylobacter bacteremia has not been sufficiently assessed. In this study we analyzed the incidence and microbiologic and clinical characteristics of Campylobacter bacteremia over 23 years.We reviewed the clinical records of all patients who had Campylobacter bacteremia from 1985 to 2007. Available strains were reidentified using universal polymerase chain reaction (PCR).During the study period, there were 71 episodes of Campylobacter bacteremia in 63 patients (0.24% of all bloodstream infections), and the incidence remained stable (mean, 0.06/1000 admissions per year and 0.47/100,000 inhabitants per year). Median age was 52 years (interquartile range, 31.25-72.5 yr), and 82% of patients were male. The underlying conditions included liver disease (21/64, 32.8%), HIV infection (15/64, 23.4%), malignancy (7/64, 10.9%), solid organ transplantation (2/64, 3%), hypogammaglobulinemia (10/64, 15.6%), and other (18/64, 31.2%). Twelve patients shared more than 1 underlying condition. Campylobacter bacteremia was community acquired in 81% of the episodes. The origin of the bloodstream infection was abdominal (43.5%), primary (26%), or extraintestinal (31%: respiratory 15%, cellulitis 4.8%, urinary 8%, other 3%). C jejuni was recovered in 66% of cases, C fetus in 19%, and C coli in 12%.Universal PCR was performed on 14 available strains. Molecular and conventional identification matched in 8 isolates. In contrast, molecular methods classified as C fetus (n = 2) and C jejuni (n = 1) 3 strains formerly identified only to genus level as Campylobacter species. In another 3 isolates, molecular identification was not consistent with the phenotypic identification (C fetus identified as C jejuni).Complications appeared in 23.9% of patients. Quinolone resistance was observed in 50% of the isolates. Only 37.8% of patients received appropriate empirical therapy. Mortality was 16.4%, although it was higher in HIV-infected patients than uninfected patients (33% vs. 10%; p = 0.04), in cases of hospital-acquired Campylobacter bacteremia compared with community-acquired cases (38.5% vs. 9.4%; p = 0.02), and in the presence of complications compared with patients without complications (100% vs. 0%; p < 0.001). The incidence of recurrence was 5% (3 patients with humoral immunodeficiency). There was a higher proportion of HIV-infected patients among patients with Campylobacter bacteremia in the pre-HAART era (1985-1996) than in the HAART era (1997-2007)-27.5% (11/40) vs. 14.3% (4/28)-although the difference was not statistically significant. Debilitating diseases such as chronic obstructive pulmonary disease emerged as predisposing conditions in the HAART era (0% before HAART era vs. 14.3% in HAART era; p = 0.032).Campylobacter bacteremia is no longer a significant disease of HIV-positive patients on HAART, but often affects other immunocompromised patients as well. Campylobacter bacteremia has an extraintestinal origin in as many as 31% of cases, and humoral immunodeficiency must be sought in patients with recurrent episodes. Quinolones should not be considered for empirical therapy.
Assuntos
Infecções por Campylobacter/epidemiologia , Infecções por Campylobacter/microbiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Antirretroviral de Alta Atividade/métodos , Infecções por Campylobacter/genética , Criança , Feminino , Predisposição Genética para Doença , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Nível de Saúde , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Estudos Prospectivos , RNA Ribossômico/genética , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Recent practice guidelines for the diagnosis of catheter-related bloodstream infection (CRBSI) describe as an "unresolved issue" the number of lumens from which blood culture specimens should be drawn to make a conservative diagnosis of CRBSI. Our objective was to determine how many CRBSI episodes would be missed if not all catheter lumens were sampled. METHODS: We performed a retrospective study (1 January 2003-31 May 2009) in patients with microbiologically proven CRBSI in which all available catheter lumens (those that did not contain clots) were used to draw blood culture samples. We calculated the number of episodes that would have been missed in double- and triple-lumen catheters if the culture of samples obtained from 1 lumens had been eliminated. RESULTS: We studied 171 episodes of proven CRBSI in 154 patients. Overall, if 1 lumen-associated culture had been eliminated for both double-lumen and triple-lumen catheters, we would have missed 27.2% and 15.8% of episodes of CRBSI, respectively. If we had eliminated 2 cultures for triple-lumen catheters, 37.3% of episodes would have been missed. CONCLUSIONS: Samples for blood culture should be obtained through all catheter lumens to establish a diagnosis of CRBSI.
