[Gastrostomy tubes: indications and infectious complications in a tertiary hospital]. / Sondas de gastrostomía: indicaciones y complicaciones infecciosas en un hospital terciario.

OBJECTIVE: Gastrostomy tube is the best option for long-term enteral nutrition. Among its limitations, infections represent the most frequent minor complication. Our aim is the knowledge of the number and type of gastrostomy tubes and its main indication in our hospital. In addition, prevalence of infectious complications was studied paying attention to the main etiologic agents and their antibiotic susceptibility. METHODS: Observational retrospective study from January 2010 to July 2015 through the electronic clinical history and the clinical microbiology laboratory software. Identification and antibiotic susceptibility of clinically significant isolates from patients with suspicion of gastrostomy tube infection have been analysed. RESULTS: Percutaneous endoscopic gastrostomy was performed in 203 patients (70.5%) and surgical gastrostomy in 85 (29.5%). The main reason identified for starting enteral nutrition through gastrostomy tube was malignant neoplasy, above all, lip, oral cavity and pharynx cancer (11.8%) and that from digestive organs (8.7%). Global prevalence of gastrostomy tube infection was 16.6%. The most common bacterial pathogens isolated were Staphylococcus aureus (21.3%), Pseudomonas aeruginosa (13.1%), and Escherichia coli (9.8%). The percentage of multi resistant isolates was 3.1%. CONCLUSIONS: Gastrostomy tube indications and type, and also, prevalence and microorganisms isolated from culture in infectious complications are similar to those described previously in the literature. The study allows the adaptation of the antibiotic prophylaxis and empirical antibiotic treatment thanks to the knowledge of the etiologic agents and their antibiotic susceptibility.

[Comparative study of treatment with quinupristin-dalfopristin alone or in combination with gentamicin, teicoplanin, imipenem or levofloxacin in experimental endocarditis due to a multidrug-resistant Enterococcus faecium]. / Comparacion de la eficacia de quinupristina-dalfopristina en monoterapia y combinada con gentamicina, teicoplanina, imipenem o levofloxacino en un modelo experimental de endocarditis por Enterococcus faecium multirresistente.

The incidence of multidrug-resistant Enterococcus faecium is increasing despite advances in antibacterial therapy. Thus, new antibiotics are required to treat hospital- or community-acquired infections caused by these multidrug-resistant organisms. The aim of this study was to compare the therapeutic efficacy of quinupristin-dalfopristin (QD) alone, or in combination with gentamicin (G), teicoplanin (T), imipenem (I) or levofloxacin (L) against a strain of multidrug-resistant E. faecium in an experimental model of aortic valve endocarditis in rabbits. The study group consisted of 28 control animals. Eighty-two animals were treated with one of the following antibiotic regimens: G1: 18 animals QD (30 mg/kg/8 h); G2: 18 animals QD+G (6 mg/kg/12 h); G3: 16 animals QD+T (20 mg/kg/12 h); G4: 14 animals QD+I (60 mg/kg/8 h); and G5: 16 animals QD+L (20 mg/kg/12 h). The response to therapy was determined by the comparison of the number of CFU/g of E. faecium in each vegetation. In vitro, time-kill studies looking for synergy for the combinations that showed better efficacy in vivo were done. The sensitivity of the strain was intermediate to QD, resistant to T and I, and sensitive to L. There was no high-level resistance to G. QD alone revealed a significant decrease (p <0.001) in the CFU/g in the control group (9.49 vs. 7.31). There were no differences in the average of CFU/g between the QD alone (G1), QD+G (G2) and QD+T (G3) groups. These three groups revealed a significant difference in decrease of CFU/g respect of the group control (p <0.001). There were no differences in the average of CFU/g between QD+I (G4) and QD+T (G5). These two groups revealed the greatest decrease in average CFU/g (G4: 4.38 and G5: 4.04) with differences respect of the group control (p <0.0001) and respect of the groups G1, G2 and G3 (p <0.001). We did not detect any alteration of MIC from QD in the course of the treatment for either of the final isolations. Only the time kill corresponding to concentrations of I 32 mg/l (0.25 x MIC) and QD 1 mg/l (0.25 x MIC presents a descending slope in the curve at 4 and 8 h, suggesting an early synergy phenomenon, which was lost after 8 h. In light of these results, the combination QD with I and L may be considered suitable alternatives for the treatment of multiresistant E. faecium.

Comparación de la eficacia de quinupristina-dalfopristina en monoterapia y combinada con gentamicina, teicoplanina, imipenem o levofloxacino en un modelo experimental de endocarditis por Enterococcus faecium multirresistente / Comparative study of treatment with quinupristin-dalfopristin alone or in combination with gentamicin, teicoplanin, imipenem or levofloxacin in experimental endocarditis due to a multidrug-resistant Enterococcus faecium

La incidencia de infecciones por Enterococcus faecium multirresistentes va aumentando a pesar de los avances que se han producido en antibioticoterapia.Por ello, se necesitan nuevos antibióticos para tratar las infecciones nosocomiales o comunitarias causadas por este microorganismo.El objetivo principal del presente estudio fue comparar la eficacia de quinupristina-dalfopristina (QD), sola o combinada con gentamicina(G), teicoplanina (T), imipenem (I) o levofloxacino (L), en un modelo de endocarditis experimental en conejos por E. faecium multirresistente.Se utilizaron 110 animales, 28 como grupo control y 82 como grupos terapéuticos, que fueron G1: 18 animales con QD (30mg/kg/8 h); G2: 18 con QD+G (6 mg/kg/12 h); G3: 16 con QD+T (20 mg/kg/12 h); G4: 14 con QD+I (60 mg/kg/8 h); y G5: 16 con QD+L(20 mg/kg/12 h). Se valoró la respuesta terapéutica comparando la concentración de E. faecium en las vegetaciones cardiacas expresada comolog10 de las unidades formadoras de colonias por gramo de tejido (UFC/g). Se realizaron pruebas de cinética de letalidad bacteriana paralas asociaciones que mostraron mejor comportamiento in vivo: QD + I y QD + L. El patrón de sensibilidad de la cepa utilizada fue: sensiblepara L, intermedia para QD, resistente para T e I, y sin resistencia de alto grado para G. El tratamiento con QD logró una reducción significativa(p <0.001) en las UFC/g respecto al grupo control (9,49 frente a 7,31). No hubo diferencias significativas entre los grupos G1 (QDsola), G2 (QD + G) y G3 (QD + T), consiguiendo estos tres grupos una redución significativa respecto del grupo control (p <0.001). No hubodiferencias entre G4 (QD + I) y G5 (QD + L). Estos dos grupos se mostraron como los más eficaces en reducir la media de UFC/g en lasvegetaciones cardiacas (G4: 4,38 y G5: 4,04), con p <0.0001 respecto al grupo control y p <0.001 respecto a G1, G2 y G3. No se detectóningún cambio en la CMI de QD durante el tratamiento. Sólo la curva de letalidad correspondiente a la concentración de I de 32 mg/l (0,25x CMI) con QD 1 mg/l (0,25 x CMI) presentó una curva descendente a las 4 y 8 horas, sugiriendo una sinergia precoz que se perdió a las 8 horas.A la vista de estos resultados, la combinación de QD con I o L podría considerarse como alternativa terapéutica en la endocarditis porE. faecium multirresistente

The incidence of multidrug-resistant Enterococcus faecium is increasing despite advances in antibacterial therapy. Thus, new antibiotics arerequired to treat hospital- or community-acquired infections caused by these multidrug-resistant organisms. The aim of this study was tocompare the therapeutic efficacy of quinupristin-dalfopristin (QD) alone, or in combination with gentamicin (G), teicoplanin (T), imipenem(I) or levofloxacin (L) against a strain of multidrug-resistant E. faecium in an experimental model of aortic valve endocarditis in rabbits. Thestudy group consisted of 28 control animals. Eighty-two animals were treated with one of the following antibiotic regimens: G1: 18 animalsQD (30 mg/kg/8 h); G2: 18 animals QD+G (6 mg/kg/12 h); G3: 16 animals QD+T (20 mg/kg/12 h); G4: 14 animals QD+I (60 mg/kg/8 h);and G5: 16 animals QD+L (20 mg/kg/12 h). The response to therapy was determined by the comparison of the number of CFU/g of E. faeciumin each vegetation. In vitro, time-kill studies looking for synergy for the combinations that showed better efficacy in vivo were done.The sensitivity of the strain was intermediate to QD, resistant to T and I, and sensitive to L. There was no high-level resistance to G. QD alonerevealed a significant decrease (p <0.001) in the CFU/g in the control group (9.49 vs. 7.31). There were no differences in the average of CFU/gbetween the QD alone (G1), QD+G (G2) and QD+T (G3) groups. These three groups revealed a significant difference in decrease of CFU/grespect of the group control (p <0.001). There were no differences in the average of CFU/g between QD+I (G4) and QD+T (G5). These twogroups revealed the greatest decrease in average CFU/g (G4: 4.38 and G5: 4.04) with differences respect of the group control (p <0.0001)and respect of the groups G1, G2 and G3 (p <0.001). We did not detect any alteration of MIC from QD in the course of the treatment for eitherof the final isolations. Only the time kill corresponding to concentrations of I 32 mg/l (0.25 x MIC) and QD 1 mg/l (0.25 x MIC presents adescending slope in the curve at 4 and 8 h, suggesting an early synergy phenomenon, which was lost after 8 h. In light of these results, thecombination QD with I and L may be considered suitable alternatives for the treatment of multiresistant E. faecium

[Implication of ermX genes in macrolide- and telithromycin-resistance in Corynebacterium jeikeium and Corynebacterium amycolatum]. / Implicacion de los genes ermX en la resistencia a los macrolidos y la telitromicina de Corynebacterium jeikeium y Corynebacterium amycolatum.

The activity of seven macrolides, clindamycin and telithromycin against clinical isolates of Corynebacterium spp. was studied. Of these, 36 isolates were identified as C. jeikeium and 57 as C. amycolatum. The frequency of resistance to erythromycin and other macrolides as well as clindamycin was high, with CMI(90) >256 microg/ml. Telithromycin showed the best activity, with 52.3% of C. amycolatum and 70% of C. jeikeium erythromycin-resistant strains susceptible to this ketolide. All strains had the MLSb constitutive phenotype. The ermX gene was present in all erythromycin-resistant strains, and in C. amycolatum was 100% homologous with that of C. striatum and C. diphtheriae.

Implicación de los genes ermX en la resistencia a los macrólidos y la telitromicina de Corynebacterium jeikeium y Corynebacterium amycolatum / Implication of ermX genes in macrolide- and telithromycin- resistance in Corynebacterium jeikeium and Corynebacterium amycolatum

Se ha estudiado la actividad de siete macrólidos, clindamicina y telitromicina frente a aislamientos clínicos del género Corynebacterium. Deéstos, 36 pertenecían a la especie C. jeikeium y 57 a C. amycolatum. Todos los macrólidos estudiados y la clindamicina presentaron escasaactividad, con CMI90 >256 mg/l. La telitromicina presentó mejor actividad, siendo sensibles un 52,3% de C. amycolatum y un 70% de C.jeikeium resistentes a la eritromicina. El fenotipo de resistencia fue de tipo MLSb constitutivo en todos los aislamientos. El gen ermX fue detectadoen el 100% de las cepas resistentes a eritromicina, presentando una homología, en el caso de C. amycolatum, de un 100% con elde C. striatum y C. diptheriae

The activity of seven macrolides, clindamycin and telithromycin against clinical isolates of Corynebacterium spp. was studied. Of these, 36isolates were identified as C. jeikeium and 57 as C. amycolatum. The frequency of resistance to erythromycin and other macrolides as wellas clindamycin was high, with CMI90 >256 ìg/ml. Telithromycin showed the best activity, with 52.3% of C. amycolatum and 70% of C. jeikeiumerythromycin-resistant strains susceptible to this ketolide. All strains had the MLSb constitutive phenotype. The ermX gene was presentin all erythromycin-resistant strains, and in C. amycolatum was 100% homologous with that of C. striatum and C. diphtheriae

In vitro activity of newer antibiotics against Corynebacterium jeikeium, Corynebacterium amycolatum and Corynebacterium urealyticum.

The in vitro activity of ciprofloxacin, erythromycin, telithromycin, teicoplanin, linezolid and quinupristin-dalfopristin was tested against human derived pathogenic corynebacteria. The MICs of these antibiotics were measured using the agar dilution method against 31 strains of Corynebacterium jeikeium, 58 Corynebacterium amycolatum (including 33 multidrug-resistant strains) and 64 Corynebacterium urealyticum clinical strains. A high resistance rate to ciprofloxacin and erythromycin was found in the three species. Telithromycin was much more active than erythromycin (MIC(90) of erythromycin >or=128 mg/l for all three species; MIC(90) of telithromycin: 4 mg/l for C. jeikeium, 64 mg/l for C. amycolatum and 1 mg/l for C. urealyticum). There were no teicoplanin-resistant (MIC(90) 1, 0.5 and 1 mg/l, respectively) or linezolid-resistant strains (MIC(90) 1, 0.2 and 0.5 mg/l, respectively). Quinupristin-dalfopristin was active against most strains with an activity similar to linezolid, but three C. jeikeium and one C. amycolatum showed MICs >or=4 mg/l. Telithromycin showed much better activity against corynebacteria than older macrolides. Synercid and linezolid were active against most isolates tested, including multidrug resistant strains.

In vitro activity of linezolid, synercid and telithromycin against genetically defined high level fluoroquinolone-resistant methicillin-resistant Staphylococcus aureus.

The in vitro activity of levofloxacin, moxifloxacin, gatifloxacin, erythromycin, telithromycin, linezolid, synercid and vancomycin was measured against 36 genetically defined, gyrA/grlA double mutant MRSA clinical strains with an MIC to ciprofloxacin > or = 8 mg/l. The three newer fluoroquinolones tested were more active than ciprofloxacin. Resistance rates for levofloxacin and gatifloxacin were high (44.5 and 36.1%, respectively). All the strains were moxifloxacin-susceptible, though most of them had MICs close to the break point. All the strains were intermediate or resistant to erythromycin and most were also resistant to telithromycin. No strains were resistant to linezolid, synercid or vancomycin (MIC(90): 2, 1 and 2 mg/l, respectively).

Molecular diversity of quinolone resistance in genetically related clinical isolates of Staphylococcus aureus and susceptibility to newer quinolones.

The genes encoding topoisomerases (gyrA and grlA) and the norA promoter of 100 fluoroquinolone-susceptible and -resistant Staphylococcus aureus clinical isolates obtained in two geographically distant hospitals were analysed. The relationship between mutations found and the susceptibility to newer quinolones was determined. Thirty-nine strains were grouped in seven clones by pulsed-field gel electrophoresis (PFGE). The remaining 61 strains were classified as unrelated strains. In three clones, all strains showed the same grlA-gyrA-norA mutation profiles. Strains in the rest of the groups showed different mutation profiles, even though PFGE indicated that they possessed genetically similar populations. One cluster showed a high level of diversity; five different mutation profiles were detected in the six isolates belonging to this pattern. Two isolates had a Glu84 to Lys mutation in grlA and another isolate had this mutation combined with a Ser84 to Leu mutation in gyrA. Combination of a Ser80 to Phe mutation in grlA and a Ser84 to Leu in gyrA was found in the two other isolates. One of these also had a thymine to a guanine transversion at a position 89 nucleotides upstream of the norA start codon in the norA promoter. These results show that fluoroquinolone resistance in clinical S. aureus strains does not necessarily result from the spread of resistant clones. Fluoroquinolone resistance may develop independently in strains belonging to the same PFGE pattern by accumulation of different mutations over a quinolone-susceptible ancestor wild type or single grlA mutant.

La significación clínica de la parasitación de strongyloides stercoralis en nuestro medio / Clinical significance of Strongyloides stercolaris parasitation in our environment

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[Activity of new quinolones against clinical isolates of Corynebacterium species]. / Actividad de nuevas quinolonasfrente a aislamientos clínicosde Corynebacterium spp.

The activity of six quinolones (ciprofloxacin, levofloxacin, trovafloxacin, moxifloxacin, clinafloxacin and grepafloxacin) against 86 clinical isolates of Corynebacterium spp. obtained from different clinical sources was studied. Of these, 30 isolates were identified as C. jeikeium, 30 as C. urealyticum and 26 as C. amycolatum. C. amycolatum was the most resistant species, with 85.5% of the strains analyzed resistant to all the quinolones studied. Clinafloxacin showed the best activity against these species with a concentration range between <0.01 and 8 mg/l, and MIC50 and MIC90 64 and 32 times lower, respectively, than the MICs of ciprofloxacin. The majority of the isolates (90%) of C. jeikeium and C. urealyticum were susceptible to all the quinolones studied. Only 9.9% of the C. jeikeium strains and 13.2% of the C. urealyticum strains were resistant to ciprofloxacin, which showed the lowest activity of the antimicrobial agents evaluated. Clinafloxacin, grepafloxacin and moxifloxacin were the most active quinolones against these two multiresistant species.

[In vitro activity of new quinolones against clinical strains of Staphylococcus aureus of the wild type and with mutations characterized by gyrA, gyrB and grlA]. / Actividad in vitro de nuevas quinolonasfrente a cepas clínicas de Staphylococcus aureussilvestres y con mutaciones caracterizadasen gyrA, gyrB y grlA.

The aim of this study was to determine the in vitro activity of five quinolones against clinical strains of methicillin-susceptible and -resistant Staphylococcus aureus clinical isolates characterized at the molecular level with respect to the presence of mutations in genes coding for resistance to quinolones (grlA, gyrA and gyrB). The relationship between the mutations found and the activities of these quinolones was also analyzed. Trovafloxacin was the most active against methicillin-susceptible S. aureus and showed good activity against methicillin-resistant S. aureus, with a MIC90 of 2 mg/l. The grlA-gyrA double mutation was the most frequent (55% of the strains). Single mutation in grlA was detected only in 5% of strains; 39% of strains showed a wild-type genotype. The grlA-gyrA double mutants presented a high level of resistance against the fluoroquinolones tested except for trovafloxacin, with the MIC ranging between 0.5 and 4 mg/l. Wild-type strains were susceptible to all the fluoroquinolones tested and the single grlA mutants had a low level of quinolone resistance but were still below the breakpoint for resistance. Trovafloxacin and sparfloxacin were less affected by this mutation.

Actividad de nuevas quinolonasfrente a aislamientos clínicosde Corynebacterium spp / Activity of new quinolones against clinical isolatesof Corynebacterium species

Se ha estudiado la actividad de seis quinolonas (ciprofloxacino, levofloxacino, trovafloxacino, moxifloxacino, clinafloxacino y grepafloxacino) frente a 86 aislamientos clínicos de Corynebacterium spp. procedentes de diferentes muestras clínicas. De éstos, 30 pertenecían a la especie C. jeikeium, 30 a C. urealyticum y 26 a C. amycolatum. La especie más resistente fue C. amycolatum, de la cual el 85,5 por ciento de las cepas estudiadas fueron resistentes a todas las quinolonas probadas, siendo clinafloxacino la que presentó una mejor actividad, con un rango de concentración entre <0,01 y 8 mg/l y CMI50 y CMI90 64 y 32 veces inferiores a las de ciprofloxacino, respectivamente. Más del 90 por ciento de las cepas de C. jeikeium y C. urealyticum fueron sensibles a todas las quinolonas, siendo ciprofloxacino la de peor actividad, con un porcentaje de cepas resistentes del 9,9 por ciento en el caso de C. jeikeium y un 13,2 por ciento para C. urealyticum. Clinafloxacino, grepafloxacino y moxifloxacino fueron las nuevas quinolonas más activas frente a estas dos especies de corinebacterias multirresistentes (AU)

Actividad in vitro de nuevas quinolonasfrente a cepas clínicas de Staphylococcus aureussilvestres y con mutaciones caracterizadasen gyrA, gyrB y grlA / In vitro activity of new quinolones against clinical strainsof Staphylococcus aureus of the wild type and with mutations characterized by gyrA, gyrB and grlA

Se ha estudiado la actividad in vitro de cinco fluoroquinolonas frente a cepas clínicas de Staphylococcus aureus, sensibles y resistentes a la meticilina, caracterizadas desde el punto de vista genético respecto a la existencia de mutaciones en los genes causantes de la resistencia a las quinolonas (grlA, gyrA y gyrB). También se comprobó el efecto de estas mutaciones en la actividad de las quinolonas. El trovafloxacino apareció como el más activo de los antimicrobianos estudiados frente a S. aureus sensibles a la meticilina (SASM), presentando también una buena actividad frente a los resistentes a ésta (SARM), con una CMI90 de 2 mg/l. El patrón más frecuente fue la doble mutación gyrA y grlA (55 por ciento de las cepas), siendo mucho menos frecuente la mutación únicamente en grlA (5 por ciento). El 39 por ciento de las cepas presentaron un genotipo silvestre. Las cepas con doble mutación presentaron altos grados de resistencia a todas las fluoroquinolonas probadas excepto a trovafloxacino, con un rango de CMI de 0,5-4 mg/l. Las cepas silvestres fueron sensibles a todas las quinolonas ensayadas; en las cinco cepas con mutación en grlA se observó un ligero aumento de las CMI para todos los antimicrobianos, aunque siempre por debajo del punto de corte que determina resistencia. Las quinolonas menos afectadas por esta mutación fueron trovafloxacino y esparfloxacino (AU)

In vitro activities of 13 fluoroquinolones against Staphylococcus aureus isolates with characterized mutations in gyrA, gyrB, grlA, and norA and against wild-type isolates.

The in vitro activities of 13 fluoroquinolones (FQs) were tested against 90 Staphylococcus aureus clinical isolates: 30 wild type for gyrA, gyrB, grlA and norA and 60 with mutations in these genes. Clinafloxacin (CI-960), sparfloxacin, and grepafloxacin were the most active FQs against wild-type isolates (MICs at which 90% of isolates were inhibited, 0.06 to 0.1 microgram/ml). Mutations in grlA did not affect the MICs of newer FQs. grlA-gyrA double mutations led to higher MICs for all the FQs tested. Efflux mechanisms affected the newer FQs to a much lesser extent than the less recently developed FQs.

Efflux pump-mediated quinolone resistance in Staphylococcus aureus strains wild type for gyrA, gyrB, grlA, and norA.

Fluoroquinolone efflux was studied in 47 Staphylococcus aureus clinical strains with MICs of ciprofloxacin (CFX) of < or = 2 micrograms/ml. Forty-three strains were wild type for gyrA, gyrB, and grlA quinolone resistance-determining regions and for norA and its promoter region. Forty of these strains (MICs of CFX, 0.1 to 0.2 microgram/ml) did not show efflux of fluoroquinolones. Three strains (MICs of CFX, 1 to 2 micrograms/ml) showed efflux. These results suggest that efflux can appear in S. aureus clinical strains in the absence of mutations in norA and its promoter.

[Antibodies studied by the ELISA technique in 60 patients with pulmonary tuberculosis. Clinico-immunological correlation]. / Estudio de anticuerpos por la técnica de ELISA en 60 enfermos de tuberculosis pulmonar. Correlación clinicoinmunológica.

The levels of IgG and IgM antibodies were evaluated in 60 patients with pulmonary tuberculosis, who were compared with a group of 30 tuberculin-negative healthy controls and another group of 10 healthy tuberculin-positive individuals. The technique for the quantification of antibodies against M. tuberculosis was an enzyme immunoassay, using purified tuberculin as antigen. The mean (means) IgG and IgM values and their standard deviations (SD), expressed in optical density units, were as follows: for the tuberculin-negative control group: IgG 0.029 +/- 0.013, IgM 0.032 +/- 0.010; for the tuberculin-positive control group: IgG 0.023 +/- 0.007, IgM 0.033 +/- 0.012; and for the group of patients: IgG 0.054 +/- 0.016, IgM 0.051 +/- 0.017. Fifty per cent of patients (30) were positive for IgG, 46.6% (28) were positive for IgM and 28.3% (17) were positive for both immunoglobulins. Those values higher than the mean of control group plus two SD were considered as positive. In the group of tuberculous patients a significant increase of IgG was observed, which was more marked after two weeks of antituberculous chemotherapy in patients with prolonged course. There appears to be a good correlation between the levels of immunoglobulins and the clinical status.