Impact of penicillin allergy records on antimicrobial prescribing in hospitalised patients.

BACKGROUND: The overdiagnosis of penicillin allergy and misclassification of non-truly allergic reactions is a growing public health problem, associated with the overuse of broad-spectrum and restricted antimicrobials. We aimed to evaluate the impact of penicillin allergy status on antimicrobial prescribing. METHODS: A retrospective study of inpatients with a documented penicillin allergy receiving antimicrobials was conducted from 1 April to 1 July 2021. Antimicrobial prescribing and clinical characteristics were compared between patients with an active penicillin allergy label and those whose label was removed following antimicrobial stewardship team review. Antimicrobials were classified in two categories: i) 'Access' (recommended), ii) 'Watch and Reserve' (restricted) according to WHO AWaRe classification, a tool to guide appropriate antibiotic use. RESULTS: 437 patients with a documented penicillin allergy receiving antimicrobials were included. 353 patients with an active penicillin allergy label, more frequently received antimicrobials from the 'Watch and Reserve list' (283;80% vs 30;37%; p<0.001). In contrast, 84 patients who were de-labelled received more often antimicrobials from the 'Access list' (53;63% vs 64;18%; p<0.001). CONCLUSIONS: Penicillin allergy reviews and de-labelling strategies may reduce the use of restricted antimicrobials under the 'Watch and Reserve list'. This practice should be encouraged and reinforced in all hospitals.

Biogas-producing microbial composition of an anaerobic digester and associated bovine residues.

Influenced by feedstock type and microbial inoculum, different microbial groups must precisely interact for high-quality biogas yields. As a first approach for optimization, this study aimed to identify through time the biogas-producing microbial community in a 10-ton dry anaerobic digester treating cattle manure by denaturing gradient gel electrophoresis (DGGE) and metagenomics. Moreover, the associated bovine residues or feedstocks (leachate, manure, oxidation lagoon water, rumen) were also characterized to determine their contribution. A diverse and dynamic community characterized by Bacteria (82%-88%) and a considerable amount of Archaea (8%-15%) presented profiles particular to each stage of biogas production. Eukaryotes (2.6%-3.6%), mainly fungi, were a minor but stable component. Proteobacteria represented 47% of the community at the start of the run but only 18% at the end, opposite to the Bacteroidetes/Chlorobi group (8% and 20%, respectively), while Firmicutes (12%-18%) and Actinobacteria (12%-32%) remained relatively constant. Methanogens of the order Methanomicrobiales represented by several species of Methanoculleus were abundant at the end of the run (77%) contrary to Methanosarcinales (11%) and Methanobacteriales (0.7%). Therefore, methanogenesis mainly occurred by the hydrogenotrophic pathway. Manure and oxidation lagoon water seemed to contribute key microorganisms, while rumen dominated by Methanobrevibacter (72%) did not proliferate in the digester. Manure particularly possessed Methanoculleus (24%) and uncultured methanogens identified by DGGE, whereas oxidation lagoon was exclusively abundant in Methanolinea (18%) and Methanosaeta (19%). Leachate, as the microbial inoculum from a previous run, adequately preserved the biogas-producing community. These results could lead to higher biogas yields through bioaugmentation strategies by incorporating higher proportions or an enriched inoculum from the relevant feedstocks.

Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study.

BACKGROUND: Hospital-acquired infection due to meticillin-resistant Staphylococcus aureus (MRSA) is common within intensive-care units. Single room or cohort isolation of infected or colonised patients is used to reduce spread, but its benefit over and above other contact precautions is not known. We aimed to assess the effectiveness of moving versus not moving infected or colonised patients in intensive-care units to prevent transmission of MRSA. METHODS: We undertook a prospective 1-year study in the intensive-care units of two teaching hospitals. Admission and weekly screens were used to ascertain the incidence of MRSA colonisation. In the middle 6 months, MRSA-positive patients were not moved to a single room or cohort nursed unless they were carrying other multiresistant or notifiable pathogens. Standard precautions were practised throughout. Hand hygiene was encouraged and compliance audited. FINDINGS: Patients' characteristics and MRSA acquisition rates were similar in the periods when patients were moved and not moved. The crude (unadjusted) Cox proportional-hazards model showed no evidence of increased transmission during the non-move phase (0.73 [95% CI 0.49-1.10], p=0.94 one-sided). There were no changes in transmission of any particular strain of MRSA nor in handwashing frequency between management phases. INTERPRETATION: Moving MRSA-positive patients into single rooms or cohorted bays does not reduce crossinfection. Because transfer and isolation of critically ill patients in single rooms carries potential risks, our findings suggest that re-evaluation of isolation policies is required in intensive-care units where MRSA is endemic, and that more effective means of preventing spread of MRSA in such settings need to be found.

Efecto del sistema de recuperación de sangre autóloga y transfusiones homólogas en pacientes quirúrgicos de alta complejidad / Effect of homologous transfusions and the autologous blood recovery system in highly complex surgical patients

Introducción: la transfusión autóloga presenta tres modalidades: transfusión autóloga con predepósito, hemodilución preoperatoria (normovolémica o hipervolémica) y el sistema de recuperación de sangre autóloga (cell saver) intraoperatoria o posoperatoria. Objetivo: demostrar la efectividad del uso del sistema de recuperación de sangre autóloga en pacientes quirúrgicos de alta complejidad en el Hospital Alcívar. Método: estudio retrospectivo, no experimental, de observación indirecta, con análisis correlacional. La muestra fue de 112 pacientes intervenidos por afecciones cardiovasculares, ortopédicas y traumatológicas, incluidos según criterios de inclusión y exclusión. Se utilizó cell saver en 56 pacientes, y 56 pacientes utilizaron transfusiones de sangre homóloga. Resultados. el cell saver fue beneficioso en 93 por ciento de los pacientes; la morbilidad y la mortalidad disminuyeron, principalmente en los pacientes intervenidos de cualquier afección cardiovascular y aumentó el índice costo/beneficio, debido a que se priorizaron los recursos económicos. En traumatología y ortopedia no fue muy beneficioso, pues la cantidad de sangre recuperada fluctuó entre 300 y 500 mL en intervenciones convencionales, lo que motivó el uso de hemoderivados y aumentó el costo. En resecciones tumorales e instrumentaciones en diferentes segmentos de la columna vertebral se recuperó hasta 800 mL de sangre, lo que resultó significativo. La tasa de complicaciones fue menor en pacientes que utilizaron cell saver (7 por ciento) frente a los pacientes que utilizaron hemoderivados homólogos (32 por ciento). Se constató una menor estancia hospitalaria en el grupo cell saver (1-20 días) en comparación con los que usaron hemoderivados homólogos (> 10 días, en 5 casos fue mayor 21 días). Conclusiones: el uso de sistema de recuperación de sangre autóloga constituye un procedimiento efectivo para infundir hemoderivados con mayor seguridad(AU)

Introduction: Autologous transfusion has three modalities: autologous transfusion with predeposit, preoperative hemodilution (normovolemic or hypervolemic), and the system for autologous blood recovery (cell saver), whether intraoperative or postoperative. Objective: To show the effectiveness of the use of the autologous blood recovery system in highly complex surgical patients at Alcívar Hospital. Method: Nonexperimental, retrospective study, of indirect observation and with correlational analysis. The sample consisted of 112 patients who underwent surgery for cardiovascular, orthopedic and traumatological conditions, chosen based on inclusion and exclusion criteria. The cell saver system was used in 56 patients and 56 patients used homologous blood transfusions. Results: The cell saver system was beneficial in 93 percent of patients; morbidity and mortality decreased, mainly in patients operated for any cardiovascular condition, while the cost-benefit ratio increased, due to the fact prioritization of economic resources. In traumatology and orthopedics, it was not so beneficial, since the amount of blood recovered fluctuated between 300 and 500 mL in conventional interventions, which motivated the use of blood products and increased the cost. In tumor resections and instrumentation of different spine segments, up to 800 mL of blood were recovered, which was significant. The complication rate was lower in patients who used the cell saver system (7 percent), compared to patients who used homologous blood products (32 percent). A shorter hospital stay was observed in the cell saver group (1-20 days), compared to those who used homologous blood products (over 10 days, while in 5 cases it was over 21 days). Conclusions: The use of the autologous blood recovery system is an effective procedure to infuse blood products with greater safety(AU)

Significados del consumo de frutas y hortalizas en dos comunidades de zona rural del municipio de Turbo, Urabá Antioqueño / The meanings of eating fruits and vegetables in two rural communities of municipality of Turbo, Uraba Antioqueño

La presente investigación tuvo como objetivo: interpretar el significado atribuido al consumo de frutas y hortalizas en un grupo de familias de Turbo. El enfoque metodológico fue cualitativo, el cual permitió comprender las realidades alimentarias de los sujetos que vivencian la situación y en los escenarios y contextos donde ocurrieron los hechos. El método utilizado fue la etnografía; las técnicas para recabar la información fueron la entrevista cualitativa, el grupo de discusión y la observación. Hallazgos: en las familias participantes quienes más consumen frutas y hortalizas son las madres y los niños menores de nueve años, éstas son también quienes enseñan a los menores a consumir dichos alimentos. A las frutas y hortalizas les atribuyen propiedades en la prevención y curación de enfermedades, principalmente respiratorias y del tracto gastrointestinal.

The present study aimed at interpreting the meaning of fruits and vegetables consumption for a group of families of Turbo. The methodological approach was qualitative, which allowed the understanding of food realities through the subjects who experience the situations, scenarios and contexts where the studied facts occurred. The method used was ethnography; the techniques for gathering information were qualitative interviewing, group discussion, and observations. Findings: Mothers and children under nine are the ones who eat more fruits and vegetables among families; mothers are also those who teach the children to consume such foods. Fruits and vegetables are regarded as helps to prevent and cure diseases, especially respiratory and gastrointestinal ones.

Importance of the environment for patient acquisition of methicillin-resistant Staphylococcus aureus in the intensive care unit: a baseline study.

OBJECTIVE: To assess the degree of environmental contamination with methicillin-resistant Staphylococcus aureus (MRSA) in critical care and the likelihood of subsequent new patient acquisition if carriers were or were not moved to single rooms. DESIGN: Randomized sequential sampling of bed areas. SETTING: Intensive care units of two teaching hospitals. PATIENTS: Medical and surgical patients requiring critical care. INTERVENTIONS: Six environmental sites around randomly selected patients plus two communal sites were sampled using contact plates during periods when patients with MRSA were physically isolated or not. Admission, weekly, and discharge screening patient swabs were taken to identify patients admitted with, or newly acquiring, MRSA. MEASUREMENTS AND MAIN RESULTS: A total of 2,436 samples were taken from environments around 114 patients, plus a further 349 samples from doctors' hands and telephones. Of the 47 bed areas where MRSA strains were identified that were not found initially on patients, only one patient subsequently acquired the same strain. Five other patients became colonized with new MRSA strains, but these were not found in their environment beforehand. Of 52 patients colonized with MRSA, 34 had a similar strain found subsequently in their environment. CONCLUSIONS: Whereas the MRSA-colonized patient frequently contaminates his or her local environment, transmission of MRSA from the environment to the patient was not commonly identified. Studies elucidating possible routes of MRSA transmission are urgently needed to inform infection control policies.

In vitro susceptibility of Gram-positive pathogens to linezolid and teicoplanin and effect on outcome in critically ill patients.

OBJECTIVES: To determine the prevalence of teicoplanin and linezolid resistance amongst Gram-positive pathogens isolated in the intensive care unit (ICU) and the impact of any resistance on clinical outcome. METHODS: Gram-positive isolates were collected from two critical care units over 1 year. All patients were screened weekly for methicillin-resistant Staphylococcus aureus (MRSA). Susceptibility to teicoplanin and linezolid was tested by Etest. The length of hospital and critical care unit stay and the use of antibiotics in each patient were recorded. RESULTS: Reduced susceptibility to teicoplanin (MIC>or=16 mg/L) was found in 21 [3.3% (95% CI 2.0-5.0%) 6 patients] of 643 strains of MRSA versus none of 374 methicillin-susceptible S. aureus (MSSA) [<0.3% (95% CI 0-0.9%)]. Of 49 enterococci 3 were teicoplanin-resistant. All Gram-positive isolates were susceptible to linezolid. The length of treatment with teicoplanin and outcome of patients infected with these strains were similar to that of susceptible strains. MRSA was a more common cause of infection than MSSA but a less frequent colonizer. CONCLUSIONS: Resistance to teicoplanin remains at a comparatively low level and there was no clear relationship between susceptibility and outcome in this critically ill population. There was no resistance in Gram-positives to linezolid but this should be kept as a reserve antibiotic to maintain its activity.

Pharmacokinetic studies of linezolid and teicoplanin in the critically ill.

OBJECTIVES: To determine the pharmacokinetic characteristics of linezolid and teicoplanin in critically ill patients. PATIENTS AND METHODS: Serum was collected frequently during day 0 and then pre- and 1 h post-dose on days 1, 2, 3, 5, 7 and every third day thereafter during treatment. Serum linezolid concentrations were analysed using HPLC. Serum teicoplanin levels were analysed by fluorescence polarization immunoassay. RESULTS: A two-compartment model was required to characterize linezolid pharmacokinetics (n=28) and account for the accumulation seen after multiple dosing. The estimated clearance was 0.049 +/-0.016 L/h/kg (+/-s.e.m. of estimate). At steady state (dosing interval 12 h), linezolid serum concentrations exceeded the breakpoint of 4 mg/L for 10.88 h (95% CI 10.09-11.66) after a 600 mg dose with an AUC/MIC of 92.4 (95% CI 57.2-127.7). Teicoplanin was best described by a two-compartment model (n=26). The clearance was 4.97+/-1.58 L/h. Serum levels exceeded the breakpoint of 4 mg/L for the entire dosing interval in all subjects (400 mg dose every 12 h) with an AUC/MIC of 399.3 (95% CI 329.6-469.0). However, only four of 14 exceeded trough serum concentrations of 10 mg/L. For both agents, trough levels were similar in those who survived and those who died. CONCLUSIONS: Linezolid dosage at 600 mg every 12 h was adequate in the critically ill without need for adjustment for renal function. For teicoplanin, further study is needed to confirm if a trough of 10 mg/L is associated with a higher rate of cure than 5 mg/L. If so, serum drug assays would be needed to ensure a therapeutic level.

Linezolid versus teicoplanin in the treatment of Gram-positive infections in the critically ill: a randomized, double-blind, multicentre study.

OBJECTIVES: Linezolid, the only commercially available oxazolidinone, is indicated for the treatment of Gram-positive infections, although little has been published specifically on its use in the critically ill. A randomized, prospective study was therefore performed to compare linezolid with the glycopeptide antibiotic, teicoplanin, for the treatment of suspected or proven Gram-positive infections in an intensive care population. METHODS: Using a double-blind, double-dummy, prospective design, patients were randomized to (i) intravenous linezolid (600 mg/12 h) plus teicoplanin dummy [one dose/12 h for three doses then every 24 h intravenously (iv)] or (ii) teicoplanin (400 mg/12 h for three doses then 400 mg/24 h iv) plus linezolid dummy (one dose/12 h iv). Other antibiotics were used in combination with the trial agents in empirical treatment. Clinical and microbiological assessments were made daily in the first week, and at 8 and 21 days after treatment. RESULTS: One hundred patients received linezolid plus placebo-teicoplanin, whereas 102 received teicoplanin plus placebo-linezolid. Population baseline characteristics were similar in both groups. At end of treatment, clinical success [71 (78.9%) linezolid versus 67 (72.8%) teicoplanin] and microbiological success [49 (70.0%) versus 45 (66.2%)] rates were similar, as were adverse effects, intensive care unit mortality, and success rates at short- and long-term follow-up. Linezolid was superior at initial clearance of methicillin-resistant Staphylococcus aureus (MRSA) colonization (end of treatment, 51.1% versus 18.6%, P = 0.002). Two MRSA isolates showed reduced susceptibility to teicoplanin. CONCLUSIONS: Linezolid has similar safety and efficacy to teicoplanin in treating Gram-positive infections in the critically ill. Short-term MRSA clearance achieved with linezolid suggests better skin and mucosal penetration.