Risk factors for infection with multidrug-resistant bacteria in non-ventilated patients with hospital-acquired pneumonia / Fatores de risco para multirresistência bacteriana em pneumonias adquiridas no hospital não associadas à ventilação mecânica

OBJECTIVE: To identify risk factors for the development of hospital-acquired pneumonia (HAP) caused by multidrug-resistant (MDR) bacteria in non-ventilated patients. METHODS: This was a retrospective observational cohort study conducted over a three-year period at a tertiary-care teaching hospital. We included only non-ventilated patients diagnosed with HAP and presenting with positive bacterial cultures. Categorical variables were compared with chi-square test. Logistic regression analysis was used to determine risk factors for HAP caused by MDR bacteria. RESULTS: Of the 140 patients diagnosed with HAP, 59 (42.1%) were infected with MDR strains. Among the patients infected with methicillin-resistant Staphylococcus aureus and those infected with methicillin-susceptible S. aureus, mortality was 45.9% and 50.0%, respectively (p = 0.763). Among the patients infected with MDR and those infected with non-MDR gram-negative bacilli, mortality was 45.8% and 38.3%, respectively (p = 0.527). Univariate analysis identified the following risk factors for infection with MDR bacteria: COPD; congestive heart failure; chronic renal failure; dialysis; urinary catheterization; extrapulmonary infection; and use of antimicrobial therapy within the last 10 days before the diagnosis of HAP. Multivariate analysis showed that the use of antibiotics within the last 10 days before the diagnosis of HAP was the only independent predictor of infection with MDR bacteria (OR = 3.45; 95% CI: 1.56-7.61; p = 0.002). CONCLUSIONS: In this single-center study, the use of broad-spectrum antibiotics within the last 10 days before the diagnosis of HAP was the only independent predictor of infection with MDR bacteria in non-ventilated patients with HAP. .

OBJETIVO: Identificar fatores de risco para o desenvolvimento de pneumonia adquirida no hospital (PAH), não associada à ventilação mecânica e causada por bactérias multirresistentes (MR). MÉTODOS: Estudo de coorte observacional retrospectivo, conduzido ao longo de três anos em um hospital universitário terciário. Incluímos apenas pacientes sem ventilação mecânica, com diagnóstico de PAH e com cultura bacteriana positiva. Variáveis categóricas foram comparadas por meio do teste do qui-quadrado. A análise de regressão logística foi usada para determinar os fatores de risco para PAH causada por bactérias MR. RESULTADOS: Dos 140 pacientes diagnosticados com PAH, 59 (42,1%) apresentavam infecção por cepas MR. As taxas de mortalidade nos pacientes com cepas de Staphylococcus aureus resistentes e sensíveis à meticilina, respectivamente, foram de 45,9% e 50,0% (p = 0,763). As taxas de mortalidade nos pacientes com PAH causada por bacilos gram-negativos MR e não MR, respectivamente, foram de 45,8% e 38,3% (p = 0,527). Na análise univariada, os fatores associados com cepas MR foram DPOC, insuficiência cardíaca crônica, insuficiência renal crônica, diálise, cateterismo urinário, infecções extrapulmonares e uso de antimicrobianos nos 10 dias anteriores ao diagnóstico de PAH. Na análise multivariada, o uso de antimicrobianos nos 10 dias anteriores ao diagnóstico foi o único fator preditor independente de cepas MR (OR = 3,45; IC95%: 1,56-7,61; p = 0,002). CONCLUSÕES: Neste estudo unicêntrico, o uso de antimicrobianos de largo espectro 10 dias antes do diagnóstico de PAH foi o único preditor independente da presença de bactérias MR em pacientes ...

Características demográficas, morbilidad y mortalidad de los pacientes adultos con neutropenia febril tratados con cefepima / Demographics, morbidity, and mortality febrile neutropenic adult patients treated with cefepime

Introduction: Cefepime efficacy for treatment of febrile neutropenia (FN) in cancer adult patients is a controversial issue. Objective: To describe the demographic characteristics and general mortality of patients suffering from febrile neutropenia treated with cefepime in a fourth-level Latin American hospital. Patients and Methods: A cross-sectional observational study was performed. Study settled at San Ignacio of Bogotá, Colombia. University Hospital from January 2004 to December 2008. Results: A total of 333 patients were treated with cefepime, of whom 125 had suffered FN and met pre established inclusion and exclusion criteria. The general mortality was 14.4%, which was similar to the overall mortality in FN in other reports. Conclusions: Although there is still no clarity regarding the efficacy of cefepime in FN, its use has not been restricted. This study did not identify an excess risk of mortality in patients treated with cefepime.

Introducción: La eficacia de cefepima en pacientes adultos con cáncer y neutropenia febril (NF) es objeto de controversia en las publicaciones científicas. Objetivo: Describir las características demográficas y la mortalidad general de los pacientes adultos con NF tratados con cefepima en un hospital latinoamericano de cuarto nivel. Pacientes y Métodos. Estudio observacional descriptivo, de corte transversal en el que se incluyeron todos los pacientes tratados con cefepima en el Hospital Universitario San Ignacio de Bogotá, Colombia entre enero de 2004 y diciembre de 2008. Resultados: Recibieron cefepime un total 333 pacientes, de los cuales 125 tenían diagnóstico de NF y cumplían criterios pre-establecidos de inclusión y exclusión. Como desenlace final se encontró una mortalidad de 14,4%, un porcentaje similar a la mortalidad general en NF reportada en la literatura médica. Conclusiones: Aún no hay claridad sobre la eficacia del uso de cefepima en NF; sin embargo, tampoco se ha proscrito su uso y los datos del presente estudio no encontraron un riesgo adicional de mortalidad.

Evaluación y manejo del adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad, en un hospital de baja complejidad, basado en la Guía Clínica Chilena / Management of community acquired pneumonia in adults following clinical guidelines at a rural hospital

Background: A National Consensus Guideline published in 2005 established the basis for the diagnostic, severity assessment and treatment of community acquired pneumonia (CAP) in the adult population. The compliance with pneumonia clinical guidelines has been associated to a reduction in hospital stay healthcare-related costs, morbidity and mortality. Aim To describe the management and outcome of non-severe CAP in hospitalized adult patients treated in a rural hospital, based on the national clinical guidelines. Patients and methods: Ninety six patients aged 74 ± 13 years (50 males) hospitalized with non-severe pneumonia (group 3) at a community-based primary care center between January 1, 2006, and March 31, 2007, were evaluated. Results: Eighty percent of patients had concomitant diseases such as hypertension in 49 percent, diabetes in 23 percent and chronic obstructive pulmonary disease in 18 percent. All were treated with a third generation cephalosporin (ceftriaxone 1-2 g/day TV) as empirical therapy. Only 9 percent of patients also received a macrolide. Early switch to oral antimicrobial therapy was successful in two third of cases. Mean hospital length of stay was 5.0 ± 2.5 days, and 30-day mortality was 6.3 percent. Conclusions: Following the recommendations of the national clinical guidelines, most of these patients had a favorable response to monotherapy with a B-lactam antimicrobial. Early switch therapy to oral antibiotic was effective and safe, reducing significantly hospital length of stay as compared to previous national clinical studies.

Acute bacterial meningitis caused by Streptococcus pneumoniae resistant to the antimicrobian agents and their serotypes / Meningite bacteriana aguda por Streptococcus pneumoniae resistente aos antimicrobianos e seus sorotipos

The main objectives of this study are to evaluate the resistance rates of Streptococcus pneumonia to penicillin G, ceftriaxone and vancomycin in patients with meningitis; to analyze possible risk factors to the antimicrobian resistance; to describe the serotypes detected and to suggest an initial empirical treatment for meningitis. The sensitiveness and serotypes of all isolated S. pneumoniae of patients with acute bacterial meningitis received by the Paraná State Central Laboratory from April 2001 to august 2002 have been evaluated. One hundred S. pneumoniae have been isolated, of which 15 percent were resistant to penicillin, 1 percent to cephalosporin and 0 percent to vancomycin. The serotypes most found were 14 (19 percent), 3 and 23F (10 percent each). When only the resistant serotypes were analyzed, the most prevalent was the 14 with 44 percent. The risk factors found in relation to the S. pneumoniae resistance were: age under one year old (p=0.01) and previous use of antibiotic (p=0.046). The resistance rates found, which were moderate to penicillin, low to cephalosporin and neutral to vancomycin, suggest the isolated use of a 3rd generation cephalosporin as an initial empirical therapy for the treatment of acute bacterial meningitis with a communitarian background.

Este estudo teve como objetivo avaliar as taxas de resistência de Streptococcus pneumoniae, isolados de pacientes com meningite, à penicilina G, ceftriaxona e vancomicina; avaliar possíveis fatores de risco para resistência antimicrobiana; descrever os sorotipos encontrados e sugerir a terapêutica empírica inicial para meningite. Foram isoladas 100 amostras de S. pneumoniae, encontrando-se 15 por cento de resistência à penicilina, 1 por cento à cefalosporina e 0 por cento à vancomicina. Os sorotipos mais encontrados foram 14 (19 por cento), 3 e 23F (10 por cento cada). Analisando-se os resistentes, o sorotipo 14 (44 por cento) também foi o mais freqüente. Os fatores de risco para resistência de S. pneumoniae encontrados foram: idade menor que um ano (p=0,01) e o uso prévio de antibiótico (p=0,046). As taxas de resistência encontradas, moderada a penicilina, baixa para cefalosporina e nula para vancomicina, sugerem como terapêutica empírica inicial para tratamento da meningite bacteriana aguda de origem comunitária, a cefalosporina de terceira geração isoladamente.

A multicenter comparative study of cefepime versus broad-spectrum antibacterial therapy in moderate and severe bacterial infections

The safety and efficacy of cefepime empiric monotherapy compared with standard broad-spectrum combination therapy for hospitalized adult patients with moderate to severe community-acquired bacterial infections were evaluated. In an open-label, multicenter study, 317 patients with an Acute Physiology and Chronic Health Evaluation (APACHE II) score ranging from >5 to =19 were enrolled with documented pneumonia (n=196), urinary tract infection (n=65), intra-abdominal infection (n=38), or sepsis (n=18). Patients were randomly assigned 1:1 to receive cefepime 1 to 2 g IV twice daily or three times a day or IV ampicillin, cephalothin, or ceftriaxone ± aminoglycoside therapy for 3 to 21 days. For both treatment groups, metronidazole, vancomycin, or macrolide therapy was added as deemed necessary. The primary efficacy variable was clinical response at the end of therapy. Two hundred ninety-six (93 percent) patients met evaluation criteria and were included in the efficacy analysis. Diagnoses included the following: 180 pneumonias (90 cefepime, 90 comparator), 62 urinary tract infections (29 cefepime, 33 comparator), 37 intra-abdominal infections (19 cefepime, 18 comparator), and 17 sepses (8 cefepime, 9 comparator). At the end of therapy, overall clinical success rates were 131/146 (90 percent) for patients treated with cefepime vs 125/150 (83 percent) for those treated with comparator (95 percent confidence interval [CI]: - 2.6 percent to 16.3 percent). The clinical success rate for patients with community-acquired pneumonia, the most frequent infection, was 86 percent for both treatment groups. Among the patients clinically evaluated, 162 pathogens were isolated and identified before therapy. The most commonly isolated pathogens were Escherichia coli (n=49), Streptococcus pneumoniae (n=29), Haemophilus influenzae (n=14), and Staphylococcus aureus (n=11). Bacteriologic eradication/presumed eradication was 97 percent for cefepime vs 94 percent for comparator-treated patients. Drug-related adverse events were reported in 16 percent of cefepime patients and 19 percent of comparator patients. In conclusion, cefepime had higher cure rates compared with broad-spectrum combination therapy as an initial empiric treatment for hospitalized patients with moderate to severe community-acquired infections, including urinary tract infections, intra-abdominal infections, and sepsis

Policondrite recidivante associada a meningoencefalite: relato de caso / Relapsing polychondritis associated with meningoencephalitis: case report

Policondrite é entidade com acometimento recorrente de qualquer cartilagem, principalmente nasal e auricular, apresenta evolução progressiva e recorrente. Está raramente associada a afecção do sistema nervoso. Descrevemos um paciente cuja manifestação inicial foi de meningoencefalite, com posterior recorrência do quadro seguido de condrite auricular e nasal. Essa associação distingue-se pela raridade e pelo fato de que o quadro neurológico antecedeu a policondrite. Seu reconhecimento permitiu o tratamento adequado e evolução satisfatória com corticosteróides e methotrexato.

Cefotaxima más amikacina asociadas a inmunomodulación en el tratamiento de actinomicetoma resistente a tratamiento convencional / Cefotaximine plus amikacin associated to immunomodulation in actinomycetoma treatment resistant to conventional therapy

El actinomicetoma es un síndrome de localización subcutánea de evolución crónica. Se presenta el caso de un paciente con micetoma abdominal causado por Nocardia brasiliensis, que había sido resistente a diferentes esquemas terapéuticos durante varios años y que, además, presentaba deficiencia en la función fagocitaria. En este caso, la curación se obtuvo con la administración de dos ciclos (con duración de 23 días cada uno); se administró cefotaxima (1g cada 8 horas) y amikacina (50 mg cada 12 horas). La inmunomodulación se llevó a cabo mediante la administración de una dosis semanal de levamisol de 300 mg, durante cuatro semanas, y la aplicación dos veces por semana de 1 ml de antígeno bacteriano a una concentración 600,000,000 de bacterias por ml durante 20 meses. Se discute la utilidad del antibiograma en estos pacientes y la importancia de la investigación de la función inmunológica en pacientes con resistencia a los tratamientos convencionales

Neumonía adquirida en el hospital: conceptos prácticos de enfoque diagnóstico y terapéutico / Pneumoniae acquired in the hospital: practical concepts of focus therapeutic and diagnosis

La neumonía adquirida en los hospitales es un problema importante y creciente en algunas latitudes y ocupa una posición protagónica en el grupo de infecciones nosocomiales. Por otra parte hay muchas dificultades diagnósticas y terapéuticas, existe abundante controversia sobre estos aspectos y finalmente por su pobre desenlace tiene consecuencias devastadoras desde el punto de vista de salud pública, aspectos económicos y sociales. Las guías de consenso ofrecen una oportunidad para orientar el problema, de otra parte, es evidente que la estrategia de lucha contra el problema es intentar prevenir la aparición de la infección por tanto se deberá fomentar de manera rigurosa la aplicación de las medidas de prevención

Complicaçöes cirúrgicas de 78 transplantes renais em crianças / Surgical complications of 78 kidney transplantation in children

Entre outubro de 1979 e novembro de 1993, foram realizados 78 transplantes renais em 73 crianças com idade entre um e 14 anos. Sessenta e dois transplantes foram realizados com doador vivo e 16 com doador-cadáver. Ocorreram oito complicaçöes cirúrgicas precoces (10,2 por cento) e quatro tardias (5,1 por cento) com quatro perdas de enxertos (5,1 por cento) no período de seguimento. Cinco complicaçöes foram de ordem vascular (6,4 por cento), seis urológicas (7,6 por cento) e uma linfocele. Houve maior incidência de complicaçöes vasculares em pacientes receptores de rim de doador-cadáver. A sobrevida atuarial de um ano do enxerto e do paciente foi de 85 por cento e 95 por cento respectivamente para receptores de rim de doador vivo e 56 por cento e 66 por cento para receptores de rim de doador-cadáver. Säo discutidos os fatores implicados na origem das complicaçöes e seu tratamento

Sensibilidad bacteriana a cefepime (Maxipime) en la Isla de Margarita: informe preliminar / Sensibility bacterium a cepefime (Maxipime) in the Isla of Margarita: cuidence preliminary

La aparición de microorganismos resistentes a múltiples antibióticos ha propiciado que los enfermos se recuperen con lentitud, permanezcan más tiempo hospitalizados y tengan gastos excesivos por el requerimiento de este servicio. Los Gramnegativos resistentes a múltiples antibióticos se reconocen como la causa más frecuente de infección intrahospitalaria. Para combatir el efecto de las bacterias resistentes a múltiples antibióticos; se dispone de cefepime, una nueva cefalosporina. En este trabajo se valoró la sensibilidad a este antibiótico en las bacterias que se aislaron con mayor frecuencia en la Isla de Margarita. Las cinco bacterias más habituales mostraron sensibilidad de 100 por ciento al cefepime, pero en casi todas la sensibilidad fue 96.42 por ciento

Osteomielite de úmero como manifestaçäo inicial da síndrome de imunodeficiência adquirida (SIDA/AIDS): relato de um caso e revisäo de literatura / Humerus osteomyelitis as initial manifestations of acquired immunodeficiency syndrome (AIDS): report of a case and literature review

Os autores descrevem um caso de osteomielite crônica do úmero provocado por Staphylococcus aureus, que se apresentou como uma das manifestaçöes iniciais da síndrome de imunodeficiência adquirida (SIDA/AIDS), em um paciente do sexo masculino, 31 anos de idade. O processo infeccioso ósseo associado ao quadro geral sugeriu a investigaçäo laboratorial para o HIV. O tratamento de escolha foi desbridamento cirúrgico e antibioticoterapia com cefalosporinas de 1ª geraçäo. Os aspectos clínicos e radiológicos säo examinados e correlacionados com estudos previamente reportados.

Dermatosis ampollar crónica benigna del niño / Benign chronic bullous dermatosis of children

Presentamos a una niña de 3 y medio años de edad que padece una dermatosis ampollar crónica benigna del niño. El diagnóstico se basa sobre criterios clínicos, anatomopatológicos, inmunológicos, terapéuticos y de microscopía electrónica. En tres estudios de inmunofluorescencia directa y en uno de inmunofluorescencia indirecta no se demonstraron anticuerpos epiteliales fijos ni circulantes. Consideramos a este como el verdadero patrón inmunológico de la DACBN ya que el hallazgo de IgA lineal en otros pacientes los hace homologables a la dermatosis ampollar IgA lineal del adulto. El estudio de antígenos de histocompatibilidad reveló un HLA B 8. Se comenta la evolución y tratamiento en 15 meses de seguimiento