[Guidelines for management of community-acquired pneumonia in adults]. / Neumonía adquirida de la comunidad en adultos. Recomendaciones sobre su atención.

Community-acquired pneumonia in adults is a common cause of morbidity and mortality particularly in the elderly and in patients with comorbidities. Most episodes are of bacterial origin, Streptococcus pneumoniae is the most frequently isolated pathogen. Epidemiological surveillance provides information about changes in microorganisms and their susceptibility. In recent years there has been an increase in cases caused by community-acquired meticillin resistant Staphylococcus aureus and Legionella sp. The chest radiograph is essential as a diagnostic tool. CURB-65 score and pulse oximetry allow stratifying patients into those who require outpatient care, general hospital room or admission to intensive care unit. Diagnostic studies and empirical antimicrobial therapy are also based on this stratification. The use of biomarkers such as procalcitonin or C-reactive protein is not part of the initial evaluation because its use has not been shown to modify the initial approach. We recommend treatment with amoxicillin for outpatients under 65 year old and without comorbidities, for patients 65 years or more or with comorbidities amoxicillin-clavulanic/sulbactam, for patients hospitalized in general ward ampicillin-sulbactam with or without the addition of clarithromycin, and for patients admitted to intensive care unit ampicillin-sulbactam plus clarithromycin. Suggested treatment duration is 5 to 7 days for outpatients and 7 to 10 for those who are hospitalized. During the influenza season addition of oseltamivir for hospitalized patients and for those with comorbidities is suggested.

[Factors associated to late clinical stage at the initiation of antiretroviral therapy]. / Factores asociados al estadio clínico avanzado en el inicio de la terapia antirretroviral.

In order to evaluate the frequency of a late clinical stage in HIV infected patients at onset of antiretroviral therapy (LART) and to identify possible associated factors, we performed a retrospective analysis of data reported in two prospective cohorts of HIV infected patients who started antiretroviral therapy for the first time between 2005 and 2009. Medical records of 265 patients -123 women (46.6%) and 141 men, median age 37.7 years old- were analyzed. LART was observed in 132 cases (50%), out of them 102 (77.2%) were associated to late diagnosis of HIV infection and 30 (22.8%) to patients that had not been retained in HIV care. The median of CD4 was 120 cells/ml and that of viral load 58 038 copies/ml. CD4 cells count was below 200 cells/ml in 174 patients (71.3%). There was a higher incidence of LART in men than in women (59.8% and 42.2% respectively). Diagnosis in women took place during pregnancy control in 25:2% of the cases. High alcohol consumption (p 0.006), single hood (p 0.04) and level of education lower than secondary (p 0.008) were associated to LART at bivariate analysis. Male sex (p 0.003) was the only associated factor both in bivariate and multivariate analysis. Our data reinforce the need of expanding HIV testing and should assist programs to define actions promoting early entry in HIV care.

[Controversies during the COVID-19 pandemic]. / Controversias durante la pandemia de COVID-19.

The COVID-19 pandemic has had an impact on public health and the global economy. The objective of this document was to update, according to the available evidence, the management of some basic elements in the Infection Control Programs (PCI) and the daily care of patients. As a result: 1. The routine use of the N95 masks is not recommended for the care of suspected or confirmed COVID-19 patients. Available data indicates that SARS-CoV-2 has spread primarily like most other common respiratory viruses, through droplet and contact transmission. In certain situations, personto-person transmission is described through the airway, observed in poorly ventilated environments, and while the individual carried out actions of greater potential transmission 2. The limited reuse and decontamination methods of N95 masks are accepted under safe and effective prot ocols in the context of limited resources. 3. The isolation of patients with COVID-19 can be lifted under a strategy based on the clinic, individual risk factors and time of evolution of the disease. 4. PCR control is not required in confirmed cases to determine epidemiological discharge. 5. Current evidence shows that there is a possibility of reinfection although its diagnosis is difficult. 6. The measurement of antibodies has a specific role in prevalence studies, diagnosis of multisystemic inflammatory syndrome and a picture compatible with negative PCR after the 7th. day.

La pandemia COVID-19 produjo un impacto en la salud pública y la economía mundial. El objetivo de este documento fue actualizar según la evidencia disponible, el manejo de algunos elementos básicos en los Programas de Control de Infecciones (PCI) y la atención diaria de los pacientes. Como resultado: 1. No se recomienda el uso rutinario de barbijo N95 para la atención de pacientes sospechosos o confirmados de COVID-19. Datos disponibles indican que el SARS-CoV-2 se ha propagado principalmente a través de la transmisión por gotas y contacto. En ciertas situaciones se describen contagios de persona a persona a través de la vía respiratoria aérea observadas en ambientes poco ventilados, y mientras el individuo realizaba acciones de mayor potencialidad de transmisión. 2. Se acepta el reúso limitado y métodos de decontaminación de máscaras/barbijos N95 bajo protocolos seguros y eficaces en el contexto de recursos limitados. 3. Se puede levantar el aislamiento de pacientes confirmados de COVID-19 bajo una estrategia basada en la clínica, factores de riesgo individuales y tiempo de evolución de la enfermedad. 4. No se requiere PCR control en casos confirmados para determinar el alta epidemiológica. 5. La evidencia actual demuestra que existe la posibilidad de reinfección, aunque su diagnóstico es dificultoso. 6. La medición de anticuerpos tiene un rol específico en estudios de prevalencia, diagnóstico de síndrome inflamatorio multisistémico y cuadro compatible con PCR negativa después del 7° día.

[Development of AIDS-related malignancies and infections after starting HAART]. / Desarrollo de neoplasias e infecciones definitorias de sida después de iniciar la terapia antirretroviral de alta eficacia.

In order to evaluate the incidence rate and possible risk factors associated with AIDS-related malignancies and infections (ARMI) we performed data analysis of clinical charts of HIV patients in two hospital cohorts, that started high activity antiretroviral therapy (HAART) between July 2003 and October 2007. Trimethoprim-sulfamethoxazole and Azithromycin prophylaxis was provided according to current guidelines. We evaluated development of ARMI six months after-starting HAART and its association with clinical and epidemiological variables. Of 235 patients analyzed -118 women (50.2%) and 117 men (49.8%)- 11 presented ARMI: 3 pulmonary TB and 3 lymph nodes TB cases, 3 cases with meningeal Cryptococcus, one Chagas's disease presenting brain mass and one with non-Hodgkin lymphoma. ARMI incidence: 4.7%. A CD4 cell count < 100/150 was associated with risk of developing ARMI. The mean CD4 cell count was 73 in patients who developed ARMI and 143 in those who did not. No association was found with the other analyzed variables. In the CD4 cell count < 150 group one out of 4 patients with reactive serology presented Chagas's disease causing brain mass; none of the 46 patients with reactive serology presented toxoplasmosis encephalitis. The incidence rate of ARMI was 4.7%. TB in first place and cryptococcosis in second were the AIDS events more frequently observed. A low CD4 cell count was the only observed risk factor statistically associated with development of ARMI. The role of prophylaxis in this population should be re-evaluated.

[Consenso Argentino Intersociedades de Infección Urinaria 2018-2019 - Parte I]. / Argentine Intersociety Consensus on Urinary Infection 2018-2019 - Part I.

The Argentine Society of Infectious Diseases and other scientific societies have updated these recommendations based on data on urinary tract infections in adults obtained from a prospective multicenter study conducted in Argentina during 2016-2017. Asymptomatic bacteriuria should be treated only in pregnant women, who should also be systematically investigated; the antibiotics of choice are nitrofurantoin, amoxicillin, clavulanic/amoxicillin, cephalexin and trimethoprim-sulfamethoxazole. In procedures involving injury to the urinary tract with bleeding, it is recommended to request urine culture and, in the presence of bacteriuria, antimicrobial treatment according to sensitivity should be prescribed from immediately before up to 24 hours after the intervention. In women, cystitis can be treated with nitrofurantoin, cephalexin or fosfomycin, while trimethoprim-sulfamethoxazole and fluoroquinolones are not recommended; pyelonephritis can be treated with ciprofloxacin, cefixime or cephalexin in ambulatory women or ceftriaxone, cefazolin or amikacin in those who are hospitalized. In men, urinary tract infections are always considered complicated; nitrofurantoin or cephalexin are recommended for 7 days, alternatively fosfomycin should be given in a single dose. In men, ciprofloxacin, ceftriaxone or cefixime are suggested for pyelonephritis on ambulatory treatment whereas ceftriaxone or amikacin are recommended for hospitalized patients. Acute bacterial prostatitis can be treated with ceftriaxone or gentamicin. Fluoroquinolones were the choice treatment for chronic bacterial prostatitis until recently; they are no longer recommended due to the increasing resistance and recent concerns regarding the safety of these drugs; alternative antibiotics such as fosfomycin are to be considered.

La Sociedad Argentina de Infectología y otras sociedades científicas han actualizado estas recomendaciones utilizando, además de información internacional, la de un estudio multicéntrico prospectivo sobre infecciones del tracto urinario del adulto realizado en Argentina durante 2016-2017. La bacteriuria asintomática debe ser tratada solo en embarazadas, a quienes también se las debe investigar sistemáticamente; los antibióticos de elección son nitrofurantoína, amoxicilina, amoxicilina-clavulánico, cefalexina y trimetoprimasulfametoxazol. Ante procedimientos que impliquen lesión con sangrado del tracto urinario se recomienda solicitar urocultivo para pesquisar bacteriuria asintomática, y, si resultara positivo, administrar antimicrobianos según sensibilidad desde inmediatamente antes hasta 24 horas luego de la intervención. En mujeres, la cistitis puede ser tratada con nitrofurantoina, cefalexina, o fosfomicina y no se recomienda usar trimetoprima-sulfametoxazol o fluoroquinolonas; en pielonefritis puede emplearse ciprofloxacina, cefixima o cefalexina si el tratamiento es ambulatorio o ceftriaxona, cefazolina o amikacina si es hospitalario. En los hombres, las infecciones del tracto urinario se consideran siempre complicadas. Se recomienda tratamiento con nitrofurantoina o cefalexina por 7 días, o bien monodosis con fosfomicina. Para la pielonefritis en hombres se sugiere ciprofloxacina, ceftriaxona o cefixima si el tratamiento es ambulatorio y ceftriaxona o amikacina si es hospitalario. Se sugiere tratar las prostatitis bacterianas agudas con ceftriaxona o gentamicina. En cuanto a las prostatitis bacterianas crónicas, si bien su tratamiento de elección hasta hace poco fueron las fluoroquinolonas, la creciente resistencia y ciertas dudas sobre la seguridad de estas drogas obligan a considerar el uso de alternativas como fosfomicina.

[Argentine Intersociety Consensus on Urinary Infection 2018-2019 - Part II]. / Consenso Argentino Intersociedades de Infección Urinaria 2018-2019 - Parte II.

The second part of the Inter-Society Argentine Consensus on Urinary Tract Infection (UTI) includes the analysis of special situations. In patients with urinary catheter, urine culture should be requested only in the presence of UTI symptomatology, before instrumentation of the urinary tract, or as a post-transplant control. The antibiotics recommended for empirical treatment in patients without risk factors are third-generation cephalosporins or aminoglycosides. UTIs associated with stones are always considered complicated. In case of obstruction with urosepsis, an emergency drainage should be performed via a percutaneous nefrostomy or ureteral stenting. In patients with stents or ureteral prostheses, such as double J catheters, empirical treatment should be based on epidemiology, prior antibiotics, and clinical status. Before the extracorporeal lithotripsy procedure, bacteriuria should be investigated and antibiotic prophylaxis should be administered in case of positive result, according to the antibiogram. First generation cephalosporins or aminoglycosides are valid alternatives. The use of antibiotic prophylaxis with first-generation cephalosporins or aminoglycosides before percutaneous nephrolithotomy is recommended. Transrectal prostatic biopsy can be associated with infectious complications, such as UTI or acute prostatitis, mainly due to Escherichia coli or other enterobacteria. In patients without risk factors for multiresistant bacteria and negative urine culture, prophylaxis with intravenous amikacin or ceftriaxone is recommended. In patients with positive urine culture, prophylaxis will be performed according to the antibiogram, from 24 hours before to 24 hours post-procedure. For the targeted treatment of post-transrectal biopsy prostatitis, carbapenems for 3-4 weeks are the treatment of choice.

La segunda parte del Consenso Argentino Intersociedades de Infección Urinaria incluye el análisis de situaciones especiales. En pacientes con sonda vesical se debe solicitar urocultivo solo cuando hay signo-sintomatología de infección del tracto urinario, antes de instrumentaciones de la vía urinaria o como control en pacientes post-trasplante renal. El tratamiento empírico recomendado en pacientes sin factores de riesgo es cefalosporinas de tercera generación o aminoglucósidos. Las infecciones del tracto urinario asociadas a cálculos son siempre consideradas complicadas. En caso de obstrucción con urosepsis, deberá realizarse drenaje de urgencia por vía percutánea o ureteral. En pacientes con stents o prótesis ureterales, como catéteres doble J, el tratamiento empírico deberá basarse en la epidemiología, los antibióticos previos y el estado clínico. Antes del procedimiento de litotricia extracorpórea se recomienda pesquisar la bacteriuria y, si es positiva, administrar profilaxis antibiótica según el antibiograma. Cefalosporinas de primera generación o aminoglúcosidos son opciones válidas. Se recomienda aplicar profilaxis antibiótica con cefalosporinas de primera generación o aminoglúcosidos antes de la nefrolitotomía percutánea. La biopsia prostática trans-rectal puede asociarse a complicaciones infecciosas, como infecciones del tracto urinario o prostatitis aguda, principalmente por Escherichia coli u otras enterobacterias. En pacientes sin factores de riesgo para gérmenes multirresistentes y urocultivo negativo se recomienda realizar profilaxis con amikacina o ceftriaxona endovenosas. En pacientes con urocultivo positivo, se realizará profilaxis según antibiograma, 24 horas previas a 24 horas post-procedimiento. Para el tratamiento dirigido de la prostatitis post-biopsia trans-rectal, los carbapenémicos durante 3-4 semanas son el tratamiento de elección.

[Characteristics of HIV infection by sex in a suburban district of Buenos Aires for the periods 1998 to 2002 and 2003 to 2005]. / Características de la infección por HIV/sida según sexo en una región del Gran Buenos Aires. Períodos 1998-2002/ 2003-2005.

With the aim of evaluating gender differences in one of the poorest districts of Buenos Aires, we reviewed epidemiological and clinical data of newly-diagnosed HIV patients at the Diego Paroissien Hospital between 1998 and 2005.We analyzed 524 clinical charts, 329 (62.8%) of which were from the 1998 to 2002 period and 195 (37.2%) from 2003 to 2005. Women accounted for 241 (46%) of the patients. The dominant mode of transmission was sexual intercourse in women and intravenous drug-use in men. At the time of diagnosis, women were at a significantly lower clinical stage, were younger, and had higher CD4 counts and lower viral loads. No gender differences were found in the rates of continued clinical care or continued antiretroviral therapy at one year follow-up. Comparing the periods 1998 to 2002 and 2003 to 2005, there was a statistically significant increase in diagnoses made during the pregnancy screening in women, in sexual transmission as the primary route of HIV infection, in the frequency of patients (both men and women) who had continued clinical care at one year follow-up, and a decreasing of intravenous drug-use in both sexes.The observed gender differences in the 2003-2005 period persisted even when those women who were diagnosed during their pregnancy screening were excluded from the analysis.

Impact of the International Nosocomial Infection Control Consortium's multidimensional approach on rates of ventilator-associated pneumonia in 14 intensive care units in 11 hospitals of 5 cities within Argentina.

BACKGROUND: To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach (IMA) on ventilator-associated pneumonia (VAP) rates in 11 hospitals within 5 cities of Argentina from January 2014-April 2017. METHODS: A multicenter, prospective, before-after surveillance study was conducted through the use of International Nosocomial Infection Control Consortium Surveillance Online System. During baseline, we performed outcome surveillance of VAP applying the definitions of the Centers for Disease Control andPrevention's National Healthcare Safety Network. During intervention, we implemented the IMA, which included a bundle of infection prevention practice interventions, education, outcome surveillance, process surveillance, feedback on VAP rates and consequences, and performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention. RESULTS: We recorded 3,940 patients admitted to 14 intensive care units. At baseline, there were 19.9 VAPs per 1,000 mechanical ventilator (MV)-days-with 2,920 MV-days and 58 VAPs, which was reduced during intervention to 9.4 VAPs per 1,000 MV-days-with 9,261 MV-days and 103 VAPs. This accounted for a 52% rate reduction (incidence density rate, 0.48; 95% confidence interval, 0.3-0.7; P .001). CONCLUSIONS: Implementing the IMA was associated with significant reductions in VAP rates in intensive care units within Argentina.

Impact of the International Nosocomial Infection Control Consortium (INICC)'s Multidimensional Approach on Rates of Central Line-Associated Bloodstream Infection in 14 Intensive Care Units in 11 Hospitals of 5 Cities in Argentina.

OBJECTIVE To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Approach (IMA) and the INICC Surveillance Online System (ISOS) on central line-associated bloodstream infection (CLABSI) rates in 14 intensive care units (ICUs) in Argentina from January 2014 to April 2017. DESIGN This prospective, pre-post surveillance study of 3,940 ICU patients was conducted in 11 hospitals in 5 cities in Argentina. During our baseline evaluation, we performed outcome and process surveillance of CLABSI applying Centers for Disease Control and Prevention/National Health Safety Network (CDC/NHSN) definitions. During the intervention, we implemented the IMA through ISOS: (1) a bundle of infection prevention practice interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback on CLABSI rates and consequences, and (6) performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention on the CLABSI rate. RESULTS During the baseline period, 5,118 CL days and 49 CLABSIs were recorded, for a rate of 9.6 CLABSIs per 1,000 central-line (CL) days. During the intervention, 15,659 CL days and 68 CLABSIs were recorded, for a rate of 4.1 CLABSIs per 1,000 CL days. The CLABSI rate was reduced by 57% (incidence density rate: 0.43; 95% confidence interval, 0.34-0.6; P<.001). CONCLUSIONS Implementing IMA through ISOS was associated with a significant reduction in the CLABSI rate in ICUs in Argentina. Infect Control Hosp Epidemiol 2018;39:445-451.

[Occupational exposure to hepatitis C virus]. / Exposicion ocupacional al virus de hepatitis C.

Occupational exposure to Hepatitis C virus is an area of growing concern due to a lack of prophylaxis and limited knowledge regarding prevalence in hospital environment. Between 1999 and 2003, a total of 128 occupational exposures to this virus were registered in Diego Paroissien Hospital, eight of which led to hepatitis (6.3%) and one case to serum conversion (0.8%). Currently there is no preventive therapy and great interest is focused on acute infection therapy the effectiveness of which is still controversial. This study reinforces the fact that adherence to the Universal Precautions is still the most important preventive measure for health care workers, and the most cost beneficial.

12 pasos para reducir la incidencia de carbapenemasas / 12 steps to mitigate the incidence of carbapenemases

La resistencia a los antimicrobianos es un grave problema para la salud mundial. Es aún más crítico en los hospitales debido a la aparición de bacterias Gram negativas resistentes a múltiples fármacos, asociadas a una alta mortalidad. Las opciones de tratamiento en estos casos son escasas, en general de alto costo. La alta densidad de consumo de antibióticos y la transmisión cruzada en este entorno amplifican este problema.Hay más evidencia del impacto de las medidas de control de infecciones que de las intervenciones de comités de antimicrobianos para mitigarlo. Además, pocos países cuentan con programas sólidos de control de infecciones para enfrentar este problema. En la presente revisión se propone una serie de 12 pasos a adoptar para mitigar la prevalencia de resistencia antimicrobiana y reducir la incidencia de carbapenemasas en las instituciones de salud. Estas recomendaciones deben interpretase como un ̈bundle ̈o paquete de medidas, en el cual todas son importantes. Aquellas que involucran la prevención de infecciones y/o colonizaciones y su diseminación son las de mayor impacto demostrado hasta ahora. Es esencial que los programas de optimización de uso de antimicrobianos cuenten con el empoderamiento de la conducción de las instituciones donde se lleven a cabo, así como también que estén constituidos por un equipo multidisciplinario eficiente, sólidamente entrenado, con metas y métricas objetivas y auditorias periódicas. También es recomendable que se incluyan recomendaciones para los tratamientos en pacientes en cuidados de fin de vida.

Antimicrobial resistance is a serious global health problem. It is even more critical in hospitals due to the emergence of multi-drug resistant Gram negative bacteria, associated with high mortality. The treatment options in these cases are scarce, generally high cost. The high density of antibiotic consumption and cross-transmission in this environment amplifies this problem.There is more evidence of the impact of Infection Control measures than of Antimicrobial Committee interventions to mitigate it. Furthermore, few countries have solid Infection Control programs to deal with this problem.This review proposes a series of 12 steps to adopt to mitigate the prevalence of antimicrobial resistance and reduce the incidence of carbapenemases in health institutions. These recommendations should be interpreted as a ̈Bundle ̈ or package of measures, in which all are important. Those that involve the prevention of infections and / or colonizations and their dissemination are the ones with the greatest impact demonstrated so far. It is essential that antimicrobial use optimization programs have the empowerment of the leadership of the institutions where they are carried out, as well as that they are constituted by an efficient multidisciplinary team, solidly trained, with objective goals and metrics and periodic audits. It is also recommended that recommendations be included for treatments in patients in end-of-life care.

Controversias durante la pandemia de COVID-19 / Controversies during the COVID-19 pandemic

Resumen La pandemia COVID-19 produjo un impacto en la salud pública y la economía mundial. El objetivo de este documento fue actualizar según la evidencia disponible, el manejo de algunos elementos básicos en los Programas de Control de Infecciones (PCI) y la atención diaria de los pacientes. Como resultado: 1. No se recomienda el uso rutinario de barbijo N95 para la atención de pacientes sospechosos o confirmados de COVID-19. Datos disponibles indican que el SARS-CoV-2 se ha propagado principalmente a través de la transmisión por gotas y contacto. En ciertas situaciones se describen contagios de persona a persona a través de la vía respiratoria aérea observadas en ambientes poco ventilados, y mientras el individuo realizaba acciones de mayor potencialidad de transmisión. 2. Se acepta el reúso limitado y métodos de decontaminación de máscaras/ barbijos N95 bajo protocolos seguros y eficaces en el contexto de recursos limitados. 3. Se puede levantar el aislamiento de pacientes confirmados de COVID-19 bajo una estrategia basada en la clínica, factores de riesgo individuales y tiempo de evolución de la enfermedad. 4. No se requiere PCR control en casos confirmados para determinar el alta epidemiológica. 5. La evidencia actual demuestra que existe la posibilidad de reinfección, aunque su diagnóstico es dificultoso. 6. La medición de anticuerpos tiene un rol específico en estudios de prevalencia, diagnóstico de síndrome inflamatorio multisistémico y cuadro compatible con PCR negativa después del 7° día.

Abstract The COVID-19 pandemic has had an impact on public health and the global economy. The objective of this document was to update, according to the available evidence, the management of some basic elements in the Infection Control Programs (PCI) and the daily care of patients. As a result: 1. The routine use of the N95 masks is not recommended for the care of suspected or confirmed COVID-19 patients. Available data indicates that SARS-CoV-2 has spread primarily like most other common respiratory viruses, through droplet and contact transmission. In certain situations, person-to-person transmission is described through the airway, observed in poorly ventilated environments, and while the individual carried out actions of greater potential transmission 2. The limited reuse and decontamination methods of N95 masks are accepted under safe and effective prot ocols in the context of limited resources. 3. The isolation of patients with COVID-19 can be lifted under a strategy based on the clinic, individual risk factors and time of evolution of the disease. 4. PCR control is not required in confirmed cases to determine epidemiological discharge. 5. Current evidence shows that there is a possibility of reinfection although its diagnosis is difficult. 6. The measurement of antibodies has a specific role in prevalence studies, diagnosis of multisystemic inflammatory syndrome and a picture compatible with negative PCR after the 7th. day.

Consenso Argentino intersociedades de Infección Urinaria 2018-2019 - Parte I / Consenso Argentino Intersociedades de Infección Urinaria 2018-2019 - Parte I

La Sociedad Argentina de Infectología y otras sociedades científicas han actualizado estas recomendaciones utilizando, además de información internacional, la de un estudio multicéntrico prospectivo sobre infecciones del tracto urinario del adulto realizado en Argentina durante 2016-2017. La bacteriuria asintomática debe ser tratada solo en embarazadas, a quienes también se las debe investigar sistemáticamente; los antibióticos de elección son nitrofurantoína, amoxicilina, amoxicilina-clavulánico, cefalexina y trimetoprima-sulfametoxazol. Ante procedimientos que impliquen lesión con sangrado del tracto urinario se recomienda solicitar urocultivo para pesquisar bacteriuria asintomática, y, si resultara positivo, administrar antimicrobianos según sensibilidad desde inmediatamente antes hasta 24 horas luego de la intervención. En mujeres, la cistitis puede ser tratada con nitrofurantoina, cefalexina, o fosfomicina y no se recomienda usar trimetoprima-sulfametoxazol o fluoroquinolonas; en pielonefritis puede emplearse ciprofloxacina, cefixima o cefalexina si el tratamiento es ambulatorio o ceftriaxona, cefazolina o amikacina si es hospitalario. En los hombres, las infecciones del tracto urinario se consideran siempre complicadas. Se recomienda tratamiento con nitrofurantoina o cefalexina por 7 días, o bien monodosis con fosfomicina. Para la pielonefritis en hombres se sugiere ciprofloxacina, ceftriaxona o cefixima si el tratamiento es ambulatorio y ceftriaxona o amikacina si es hospitalario. Se sugiere tratar las prostatitis bacterianas agudas con ceftriaxona o gentamicina. En cuanto a las prostatitis bacterianas crónicas, si bien su tratamiento de elección hasta hace poco fueron las fluoroquinolonas, la creciente resistencia y ciertas dudas sobre la seguridad de estas drogas obligan a considerar el uso de alternativas como fosfomicina.

The Argentine Society of Infectious Diseases and other scientific societies have updated these recommendations based on data on urinary tract infections in adults obtained from a prospective multicenter study conducted in Argentina during 2016-2017. Asymptomatic bacteriuria should be treated only in pregnant women, who should also be systematically investigated; the antibiotics of choice are nitrofurantoin, amoxicillin, clavulanic/amoxicillin, cephalexin and trimethoprim-sulfamethoxazole. In procedures involving injury to the urinary tract with bleeding, it is recommended to request urine culture and, in the presence of bacteriuria, antimicrobial treatment according to sensitivity should be prescribed from immediately before up to 24 hours after the intervention. In women, cystitis can be treated with nitrofurantoin, cephalexin or fosfomycin, while trimethoprim-sulfamethoxazole and fluoroquinolones are not recommended; pyelonephritis can be treated with ciprofloxacin, cefixime or cephalexin in ambulatory women or ceftriaxone, cefazolin or amikacin in those who are hospitalized. In men, urinary tract infections are always considered complicated; nitrofurantoin or cephalexin are recommended for 7 days, alternatively fosfomycin should be given in a single dose. In men, ciprofloxacin, ceftriaxone or cefixime are suggested for pyelonephritis on ambulatory treatment whereas ceftriaxone or amikacin are recommended for hospitalized patients. Acute bacterial prostatitis can be treated with ceftriaxone or gentamicin. Fluoroquinolones were the choice treatment for chronic bacterial prostatitis until recently; they are no longer recommended due to the increasing resistance and recent concerns regarding the safety of these drugs; alternative antibiotics such as fosfomycin are to be considered.

Consenso Argentino intersociedades de Infección Urinaria 2018-2019 - Parte II / Argentine Intersociety Consensus on Urinary Infection 2018-2019 - Part II

La segunda parte del Consenso Argentino Intersociedades de Infección Urinaria incluye el análisis de situaciones especiales. En pacientes con sonda vesical se debe solicitar urocultivo solo cuando hay signo-sintomatología de infección del tracto urinario, antes de instrumentaciones de la vía urinaria o como control en pacientes post-trasplante renal. El tratamiento empírico recomendado en pacientes sin factores de riesgo es cefalosporinas de tercera generación o aminoglucósidos. Las infecciones del tracto urinario asociadas a cálculos son siempre consideradas complicadas. En caso de obstrucción con urosepsis, deberá realizarse drenaje de urgencia por vía percutánea o ureteral. En pacientes con stents o prótesis ureterales, como catéteres doble J, el tratamiento empírico deberá basarse en la epidemiología, los antibióticos previos y el estado clínico. Antes del procedimiento de litotricia extracorpórea se recomienda pesquisar la bacteriuria y, si es positiva, administrar profilaxis antibiótica según el antibiograma. Cefalosporinas de primera generación o aminoglúcosidos son opciones válidas. Se recomienda aplicar profilaxis antibiótica con cefalosporinas de primera generación o aminoglúcosidos antes de la nefrolitotomía percutánea. La biopsia prostática trans-rectal puede asociarse a complicaciones infecciosas, como infecciones del tracto urinario o prostatitis aguda, principalmente por Escherichia coli u otras enterobacterias. En pacientes sin factores de riesgo para gérmenes multirresistentes y urocultivo negativo se recomienda realizar profilaxis con amikacina o ceftriaxona endovenosas. En pacientes con urocultivo positivo, se realizará profilaxis según antibiograma, 24 horas previas a 24 horas post-procedimiento. Para el tratamiento dirigido de la prostatitis post-biopsia trans-rectal, los carbapenémicos durante 3-4 semanas son el tratamiento de elección.

The second part of the Inter-Society Argentine Consensus on Urinary Tract Infection (UTI) includes the analysis of special situations. In patients with urinary catheter, urine culture should be requested only in the presence of UTI symptomatology, before instrumentation of the urinary tract, or as a post-transplant control. The antibiotics recommended for empirical treatment in patients without risk factors are third-generation cephalosporins or aminoglycosides. UTIs associated with stones are always considered complicated. In case of obstruction with urosepsis, an emergency drainage should be performed via a percutaneous nefrostomy or ureteral stenting. In patients with stents or ureteral prostheses, such as double J catheters, empirical treatment should be based on epidemiology, prior antibiotics, and clinical status. Before the extracorporeal lithotripsy procedure, bacteriuria should be investigated and antibiotic prophylaxis should be administered in case of positive result, according to the antibiogram. First generation cephalosporins or aminoglycosides are valid alternatives. The use of antibiotic prophylaxis with first-generation cephalosporins or aminoglycosides before percutaneous nephrolithotomy is recommended. Transrectal prostatic biopsy can be associated with infectious complications, such as UTI or acute prostatitis, mainly due to Escherichia coli or other enterobacteria. In patients without risk factors for multiresistant bacteria and negative urine culture, prophylaxis with intravenous amikacin or ceftriaxone is recommended. In patients with positive urine culture, prophylaxis will be performed according to the antibiogram, from 24 hours before to 24 hours post-procedure. For the targeted treatment of post-transrectal biopsy prostatitis, carbapenems for 3-4 weeks are the treatment of choice.

Neumonía asociada a cuidados de la salud: revisión de la evidencia publicada / Health-care associated pneumonia: review of published evidence

El concepto de neumonía asociada a cuidados de la salud (NACS) surgió a partir de la presunción de que los patógenos causantes del cuadro tendrían mayores probabilidades de ser microorganismos multiresistentes (MOMR), por lo que el esquema de tratamiento antibiótico debía ser diferente al requerido en neumonía adquirida en la comunidad (NAC). Sin embargo, la evidencia que sustenta esa idea no es lo suficientemente robusta. Dado lo complejo del tema, y su elevado impacto en el consumo exagerado de antibióticos, se presenta esta revisión. Es posible que la ausencia de los factores de riesgo usualmente descriptos, o la presencia de solo uno, sugiera poca probabilidad deMOMR, por lo que el abordaje terapéutico debería ser similaral de NAC. Por el contrario, ante la acumulación de factoresde riesgo o frente a cuadros severos se podría considerarla cobertura de MOMR mediante un esquema de espectroampliado

The concept of health-care-associated pneumonia (HCAP) arose from the presumption that the pathogens that cause the disease would be more likely to be multi-resistant microorganisms (MRMO), so the antibiotic treatment scheme should be different from the one required in community acquired pneumonia (CAP). However, the evidence supporting this idea is not robust enough. Given the complexity of the topic, and its high impact on the exaggerated consumption of antibiotics, this review is presented. It is possible that the absence of risk factors usually described, or the presence of only one, suggests a low probability of MRMO, so the therapeutic approach should be similar to that ofCAP. On the contrary, in view of the accumulation of risk factors or in severecases, MRMO coverage could be considered, through an extended spectrum scheme

Neumonía adquirida de la comunidad en adultos: Recomendaciones sobre su atención / Guidelines for management of community-acquired pneumonia in adults

La neumonía adquirida en la comunidad (NAC) en adultos es causa frecuente de morbilidad y mortalidad, especialmente en adultos mayores y en sujetos con comorbilidades previas. La mayoría de los episodios son de etiología bacteriana, Streptococcus pneumoniae es el patógeno aislado con mayor frecuencia. La vigilancia epidemiológica permite conocer los cambios en los microorganismos productores y su sensibilidad a los antimicrobianos; recientemente se ha observado un incremento en aislamientos de Staphylococcus aureus resistente a la meticilina y Legionella sp. La radiografía de tórax resulta imprescindible como herramienta diagnóstica. El score CURB-65 y la oximetría de pulso permiten estratificar a los pacientes en aquellos que requieren manejo ambulatorio, hospitalización en sala general o unidad de terapia intensiva. Los estudios diagnósticos y el tratamiento antimicrobiano empírico también se basan en esta estratificación. Los biomarcadores tales como procalcitonina o proteína-C reactiva no son parte de la evaluación inicial dado que su utilización no demostró modificar el manejo de los episodios de NAC. El tratamiento antibiótico sugerido para pacientes ambulatorios menores de 65 años sin comorbilidades es amoxicilina; pacientes ≥ 65 años o con comorbilidades: amoxicilina-clavulánico/sulbactam; hospitalizados en sala general: ampicilina sulbactam con o sin claritromicina; pacientes admitidos a unidad de terapia intensiva: ampicilina-sulbactam más claritromicina. La duración del tratamiento es de 5 a 7 días para tratamiento ambulatorio y 7 a 10 para los hospitalizados. En época de circulación del virus de la influenza se sugiere el agregado de oseltamivir para los pacientes hospitalizados y para aquellos con comorbilidades.

Community-acquired pneumonia in adults is a common cause of morbidity and mortality particularly in the elderly and in patients with comorbidities. Most episodes are of bacterial origin, Streptococcus pneumoniae is the most frequently isolated pathogen. Epidemiological surveillance provides information about changes in microorganisms and their susceptibility. In recent years there has been an increase in cases caused by community-acquired meticillin resistant Staphylococcus aureus and Legionella sp. The chest radiograph is essential as a diagnostic tool. CURB-65 score and pulse oximetry allow stratifying patients into those who require outpatient care, general hospital room or admission to intensive care unit. Diagnostic studies and empirical antimicrobial therapy are also based on this stratification. The use of biomarkers such as procalcitonin or C-reactive protein is not part of the initial evaluation because its use has not been shown to modify the initial approach. We recommend treatment with amoxicillin for outpatients under 65 year old and without comorbidities, for patients 65 years or more or with comorbidities amoxicillin-clavulanic/sulbactam, for patients hospitalized in general ward ampicillin-sulbactam with or without the addition of clarithromycin, and for patients admitted to intensive care unit ampicillin-sulbactam plus clarithromycin. Suggested treatment duration is 5 to 7 days for outpatients and 7 to 10 for those who are hospitalized. During the influenza season addition of oseltamivir for hospitalized patients and for those with comorbidities is suggested.

[A study of occupational blood and body fluid exposure among nursing staff at a reference hospital in Buenos Aires, Argentina]. / Estudio sobre la exposición ocupacional a sangre y fluidos corporales en el personal de enfermería de un hospital de referencia de Buenos Aires, Argentina.

OBJECTIVES: To determine the frequency of occupational blood and body fluids exposure (OBBFE) among the nursing staff at the Dr. Diego Paroissien Hospital in Buenos Aires, Argentina; analyze the possible risk factors associated; and assess the level of knowledge regarding universal precautions and control procedures following exposure: METHODS: A cross-sectional descriptive study was performed using a voluntary and anonymous survey administered between April and May 2005. In addition to personal and professional data, information was collected on knowledge and practice of universal precautions and procedures, OBBFE experienced, barriers to following the standards, and whether or not the Hepatitis B vaccine had been received. The dependent variable in the analysis was ever having experienced an OBBFE accident: RESULTS: Of the 186 responses analyzed, 77.7% were female, the mean age was 44.6 +/- 8.9 years, and the institution was 13.3 +/- 6.4 years old. Of those surveyed, 91 (48.9%) indicated that at some time they had an OBBFE, with 33 (17.7%) of these having occurred during the previous year; 73.0% confirmed that the tools necessary for complying with universal precautions were available always or almost always; 76.2% felt they had complete information, although 56.3% said they had not received adequate training; and, 94.1% claimed to have been vaccinated against Hepatitis B. Being overworked (54.5%), insufficient training (21.8%), and a lack of protective tools (18.8%) were the reasons most often identified as impeding compliance with universal precaution guidelines. Not having received training during the preceding year and having recently started work in a clinical or adult intensive-care unit were significantly associated with having experienced an OBBFE: CONCLUSIONS: These results signal a risk alert for OBBFE among health care workers and underscore the need for improving standards and surveillance.

Factores asociados al estadio clínico avanzado en el inicio de la terapia antirretroviral / Factors associated to late clinical stage at the initiation of antiretroviral therapy

A fin de evaluar la frecuencia y posibles factores asociados a la presencia de estadio clínico avanzado al inicio de terapia antirretroviral (ECAITA), efectuamos un análisis retrospectivo de datos de dos cohortes prospectivas de pacientes infectados por HIV que iniciaron terapia antirretroviral (sin tratamiento anterior) entre 2005 y 2009. Se analizaron las historias clínicas de 264 pacientes, 123 mujeres (46.6%) y 141 hombres (53.4%). La mediana de edad fue de 37.7 años. Observamos ECAITA en 132 casos (50%), de los cuales 102 (77.2%) se asociaron a diagnóstico tardío de infección por HIV y 30 (22.8%) a pacientes con diagnóstico previo no retenidos en el cuidado clínico de la salud. La mediana de células CD4 fue 120/ml y de carga viral 58 038 copias/ml. El recuento de células CD4 era inferior a 200 cel/ml en 174 pacientes (71.3%). Los hombres presentaron ECAITA con mayor frecuencia que las mujeres (59.8% vs. 40.2%), en quienes el diagnóstico se realizó durante el control de un embarazo en el 25.2% de los casos. Consumo elevado de alcohol (p 0.006), ser soltero (p 0.04) y nivel de educación menor al secundario completo (p 0.008) se asociaron a ECAITA en el análisis bivariado. Ser de sexo masculino (p 0.003) fue el único factor asociado tanto en el análisis bivariado como en el multivariado. Nuestros datos refuerzan la necesidad de expandir el testeo para HIV y deberían impulsar a definir acciones programáticas que promuevan el ingreso precoz al cuidado de la infección por HIV.

In order to evaluate the frequency of a late clinical stage in HIV infected patients at onset of antiretroviral therapy (LART) and to identify possible associated factors, we performed a retrospective analysis of data reported in two prospective cohorts of HIV infected patients who started antiretroviral therapy for the first time between 2005 and 2009. Medical records of 265 patients -123 women (46.6%) and 141 men, median age 37.7 years old- were analyzed. LART was observed in 132 cases (50%), out of them 102 (77.2%) were associated to late diagnosis of HIV infection and 30 (22.8%) to patients that had not been retained in HIV care. The median of CD4 was 120 cells/ml and that of viral load 58 038 copies/ml. CD4 cells count was below 200 cells/ml in 174 patients (71.3%). There was a higher incidence of LART in men than in women (59.8% and 42.2% respectively). Diagnosis in women took place during pregnancy control in 25:2% of the cases. High alcohol consumption (p 0.006), single hood (p 0.04) and level of education lower than secondary (p 0.008) were associated to LART at bivariate analysis. Male sex (p 0.003) was the only associated factor both in bivariate and multivariate analysis. Our data reinforce the need of expanding HIV testing and should assist programs to define actions promoting early entry in HIV care.

Factores asociados al estadio clínico avanzado en el inicio de la terapia antirretroviral / Factors associated to late clinical stage at the initiation of antiretroviral therapy

A fin de evaluar la frecuencia y posibles factores asociados a la presencia de estadio clínico avanzado al inicio de terapia antirretroviral (ECAITA), efectuamos un análisis retrospectivo de datos de dos cohortes prospectivas de pacientes infectados por HIV que iniciaron terapia antirretroviral (sin tratamiento anterior) entre 2005 y 2009. Se analizaron las historias clínicas de 264 pacientes, 123 mujeres (46.6%) y 141 hombres (53.4%). La mediana de edad fue de 37.7 años. Observamos ECAITA en 132 casos (50%), de los cuales 102 (77.2%) se asociaron a diagnóstico tardío de infección por HIV y 30 (22.8%) a pacientes con diagnóstico previo no retenidos en el cuidado clínico de la salud. La mediana de células CD4 fue 120/ml y de carga viral 58 038 copias/ml. El recuento de células CD4 era inferior a 200 cel/ml en 174 pacientes (71.3%). Los hombres presentaron ECAITA con mayor frecuencia que las mujeres (59.8% vs. 40.2%), en quienes el diagnóstico se realizó durante el control de un embarazo en el 25.2% de los casos. Consumo elevado de alcohol (p 0.006), ser soltero (p 0.04) y nivel de educación menor al secundario completo (p 0.008) se asociaron a ECAITA en el análisis bivariado. Ser de sexo masculino (p 0.003) fue el único factor asociado tanto en el análisis bivariado como en el multivariado. Nuestros datos refuerzan la necesidad de expandir el testeo para HIV y deberían impulsar a definir acciones programáticas que promuevan el ingreso precoz al cuidado de la infección por HIV.(AU)

In order to evaluate the frequency of a late clinical stage in HIV infected patients at onset of antiretroviral therapy (LART) and to identify possible associated factors, we performed a retrospective analysis of data reported in two prospective cohorts of HIV infected patients who started antiretroviral therapy for the first time between 2005 and 2009. Medical records of 265 patients -123 women (46.6%) and 141 men, median age 37.7 years old- were analyzed. LART was observed in 132 cases (50%), out of them 102 (77.2%) were associated to late diagnosis of HIV infection and 30 (22.8%) to patients that had not been retained in HIV care. The median of CD4 was 120 cells/ml and that of viral load 58 038 copies/ml. CD4 cells count was below 200 cells/ml in 174 patients (71.3%). There was a higher incidence of LART in men than in women (59.8% and 42.2% respectively). Diagnosis in women took place during pregnancy control in 25:2% of the cases. High alcohol consumption (p 0.006), single hood (p 0.04) and level of education lower than secondary (p 0.008) were associated to LART at bivariate analysis. Male sex (p 0.003) was the only associated factor both in bivariate and multivariate analysis. Our data reinforce the need of expanding HIV testing and should assist programs to define actions promoting early entry in HIV care.(AU)

Desarrollo de neoplasias e infecciones definitorias de sida después de iniciar la terapia antirretroviral de alta eficacia / Development of AIDS-related malignancies and infections after starting HAART

Con el objetivo de evaluar la incidencia de neoplasias e infecciones definitorias de Sida (NIDS) y los posibles factores asociados a su desarrollo luego de iniciada la terapia antirretroviral de alta eficacia (HAART) analizamos las historias clínicas de los pacientes que iniciaron tratamiento entre julio 2003 y octubre 2007. Todos recibieron profilaxis con trimetoprima-sulfametoxazol y azitromicina según la recomendación actual. Evaluamos el desarrollo de NIDS en los 6 meses posteriores al inicio de la terapia y su asociación con variables clínicas y epidemiológicas. Analizamos 235 historias clínicas: 118 mujeres (50.2%) y 117 hombres (49.8%). Observamos 11 casos de NIDS: 3 formas pulmonares y 3 ganglionares de tuberculosis, 3 meningitis por Criptococcus neoformans, 1 chagoma cerebral y 1 linfoma no Hodgkin. Presentar recuento de células CD4 menor a 100 o 150 células/ml se asoció con riesgo de desarrollar NIDS. La media de células CD4 fue 73 en los pacientes que desarrollaron NIDS y 143 en los que no la desarrollaron. No hubo asociación con las otras variables analizadas. En pacientes con CD4 menor a 150 células/ml observamos un caso de chagoma cerebral entre 4 con serología reactiva para Chagas, y ninguno de toxoplasmosis cerebral entre 46 con serología reactiva para toxoplasmosis. Concluimos que la tasa de incidencia de NIDS fue del 4.7%, siendo tuberculosis en primer lugar y criptococosis en segundo las enfermedades más frecuentemente observadas. Presentar bajo recuento de células CD4 se asoció de manera significativa al desarrollo de NIDS. Debería reevaluarse el rol de la quimioprofilaxis.

In order to evaluate the incidence rate and possible risk factors associated with AIDS-related malignancies and infections (ARMI) we performed data analysis of clinical charts of HIV patients in two hospital cohorts, that started high activity antiretroviral therapy (HAART) between July 2003 and October 2007. Trimethoprim-sulfamethoxazole and azytromicin prophylaxis was provided according to current guidelines. We evaluated development of ARMI six months after-starting HAART and its association with clinical and epidemiological variables. Of 235 patients analyzed -118 women (50.2%) and 117 men (49.8%)- 11 presented ARMI: 3 pulmonary TB and 3 lymph nodes TB cases, 3 cases with meningeal Cryptococcus, one Chagas' disease presenting brain mass and one with non-Hodgkin lymphoma. ARMI incidence: 4.7%. A CD4 cell count < 100/150 was associated with risk of developing ARMI. The mean CD4 cell count was 73 in patients who developed ARMI and 143 in those who did not. No association was found with the other analyzed variables. In the CD4 cell count < 150 group one out of 4 patients with reactive serology presented Chagas's disease causing brain mass; none of the 46 patients with reactive serology presented toxoplasmosis encephalitis. The incidence rate of ARMI was 4.7%. TB in first place and cryptococcosis in second were the AIDS events more frequently observed. A low CD4 cell count was the only observed risk factor statistically associated with development of ARMI. The role of prophylaxis in this population should be re-evaluated.