Alberto Fica C

Tuberculosis en el personal de salud

Resumen La tuberculosis (TBC) es un riesgo ocupacionalque explica entre 5 y 5.361 casos por 100.000 personasen el personal de salud (PS) por sobre la poblaciongeneral en paises en vias de desarrollo. Cada casoclinico implica que han ocurrido muchos casos deinfeccion. Esta infeccion puede ser detectada por laprueba de conversion de tuberculina entre personasno vacunadas o por prueba de liberacion de gamainterferon. Los factores de riesgo incluyen la frecuen-cia de pacientes con TBC atendidos, la funcion y lugarde trabajo del PS, retraso en la sospecha diagnostica,atencion de pacientes con cepas multi-resistentes, sis-temas de ventilacion limitados, falta de aplicacion deprecauciones por aerosoles y PS con inmunosupresiono desnutricion. Los estudios moleculares han permiti-do aclarar que solo 32 a 42% de los casos en el PSresponde a adquisicion ocupacional. Las medidas uti-les para prevenir este riesgo incluyen un conjunto dedisposiciones administrativas, de infraestructura y pre-cauciones en el personal que han permitido reducir elriesgo de infeccion, y en ocasiones el de TBC clinica,en el PS. En Chile existen actualmente dos normasreguladoras sobre la materia, una del Programa Nacio-nal de la TBC y el otro del Programa de InfeccionesIntrahospitalarias, las que difieren en algunos aspec-tos sustantivos y que ameritan una revision.

Alta incidencia de diarrea por Clostridium difficile en pacientes nefrológicos

Background: Clostridium difficile is the main agent causing antimicrobial associated nosocomial diarrhea. Chronic renal failure is a risk factor for this type of diarrhea. Aim: To study the incidence and complications of Clostridium difficile diarrhea in a university hospital and among patients with renal diseases. Patients and methods: Retrospective review of all cases of Clostridium difficile diarrhea that occurred in a university hospital, between June 2000 and May 2001. Results: In the Nephrology Unit, 48 episodes of Clostridium difficile diarrhea occurred in 35 patients (7 cases per 100 discharges/year). This figure is higher than the global incidence in the hospital (0.53 cases per 100 discharges/year, p <0.001). The mean age of the 33 patients with renal diseases was 63 years old and 17 of them were female. Their main diagnoses were chronic renal failure in hemodialysis in 48%, uremic syndrome in 36% and renal transplant in 6%. Seventy nine percent had a history of antimicrobial use (42% quinolones and 36% cephalosporins). In 3 patients, the only risk factor was chronic renal failure. Seventy five percent responded to metronidazole and in 27%, diarrhea recidivated, compared with a 6% recurrence rate in other units, p <0.02). Eight patients died during hospital stay. Conclusions: Among patients with renal diseases, Clostridium difficile is frequent and associated with a high recurrence rate and mortality. Chronic renal failure may be a risk factor for its development (Rev Med Chile 2003; 131: -).

Espondilodiscitis: Análisis de una serie de 25 casos

Background: Spondylodiscitis is a rare but prolonged inflammation of two adjacent vertebral bodies and the disk in between. Aim: To report the clinical features of a series of patients with spondylodiscitis. Material and methods: A retrospective analysis of medical records of patients with spondylitis, identified between 1989 and 2002. Results: A total of 25 cases were identified, 15 female, aged 49.8 years as a mean. Their mean evolution before admission was 4.3 months. Main complaints were back or radicular pain. Mild anemia was present in most patients. Mean erythrocyte sedimentation rate and C reactive protein values were 66 mm/h and 60 mg/L, respectively. Forty four percent of patients had neurological complications. Vertebral computed tomography and scintigraphic studies were done in 72% of patients, but magnetic resonance imaging was done only in 4 (16%). In 18 patients, a tissue sample for pathological and microbiological analysis, was obtained by imaging guiding or surgically. Tuberculosis, diagnosed on pathology, was the leading cause of spondylitis in nine cases (36%), followed by Staphylococcus aureus infection in five (20%). Other agents found were E coli and group D Streptococcus (one each). Age, symptoms, evolution time and different laboratory parameters did not differ between patients with tuberculosis and patients with other causes. A microbiological cause was not established in 36% of cases. Most patients evolved satisfactorily and recovered from neurological complications (88%). One patient with tuberculosis did not improve after prolonged treatment and 2 patients infected with S aureus died (8%). Conclusions: Spondylodiscitis is associated to a diversity of microbial agents and in most cases has a favorable prognosis (Rev Med Chile 2003; 131: 473-82).

Prevención de infecciones asociadas a catéteres vasculares centrales

laprimera causa en adultos o ninos (34 y 24,7%,respectivamente). Para el mismo ano, las tasasde infecciones del torrente sanguineo asociadas anutricion parenteral o a hemodialisis, fueron si-milares (4,1 y 3,8 por 1.000, respectivamente).Salvo la disminucion de estas tasas observadasen los Servicios de Medicina, Cirugia o Neonato-logia en los ultimos anos, la magnitud de esteproblema no decrece en general y continua re-presentando un riesgo importante, ya sea si elcateter es utilizado para monitorizacion hemo-dinamica, administracion de farmacos, hemoderi-vados, nutricion parenteral o hemodialisis.Aunque los datos presentados por el MINSALsobreestiman de alguna manera la verdadera inci-dencia de bacteremias asociadas a cateteresvasculares centrales (CVCs) debido a la utiliza-cion de definiciones amplias en un sistema devigilancia activa, ello no disminuye la gran impor-tancia de estas infecciones en el trabajo clinicocotidiano.La incidencia de infecciones asociadas alcateterismo vascular varia dependiendo de facto-res del huesped, del cateter y la intensidad de lamanipulacion. Factores especificos descritos co-rresponden al material del cateter, ubicacion,metodo de instalacion, instalacion electiva o deurgencia, numero de lumenes, duracion de lacateterizacion y caracteristicas del huesped (que-mados, recien nacidos de muy bajo peso)

Cambios epidemiológicos de las salmonelosis en Chile: Desde Salmonella typhi a Salmonella enteritidis

Chile ha experimentado un cambio epidemiologico en la ultima decada con la desaparicion progresiva de la fiebre tifoidea causada mayoritariamente por Salmonella typhi y la emergencia epidemica de Salmonella enteritidis, un agente de diarrea sin tratamiento especifico eficaz y ligado estrechamente a productos avicolas contaminados e inadecuadamente preparados. La fiebre tifoidea ha disminuido su importancia debido al desarrollo humano experimentado en Chile que ha significado un alto grado de cobertura de agua potable y de manejo de excretas, en conjunto con un mayor nivel de educacion, factores que limitan la contaminacion del ambiente por este agente y la adquisicion de el por huespedes susceptibles. A pesar de este notable avance, un nuevo serotipo de salmonela ha irrumpido en Chile, denominado enteritidis, que ha logrado aprovechar el nuevo escenario logrado con la industrializacion avicola donde miles de aves ahora conviven en pequenos espacios facilitando la infeccion cruzada entre ellas. La contaminacion intermitente de huevos por via transovarica o superficial permite la llegada de este agente en forma erratica pero persistente al ser humano. Este nuevo escenario y la ausencia de un tratamiento antimicrobiano eficaz para este agente, obligan a que nuestro pais adopte nuevas estrategias de prevencion que involucran a productores, distribuidores y consumidores de productos avicolas

Detección de Salmonella enteritidis en muestras de productos avícolas de consumo humano en la Región Metropolitana

Background: Salmonella enteritidis (SE) is a frequent cause of diarrhea, and is transmitted mainly by SE contaminated eggs or poultry meat. The frequency of SE contaminated eggs or chicken meat and the risk for acquiring this pathogen is unknown in Chile. Aim: To measure SE contamination in eggs poultry meat and entrails offered in retail markets in the Metropolitan Area during two consecutive years (1998-1999). Material and methods: Samples were placed in sterile bags and transported to the laboratory before 4 hours at 4°C. Microbiologic detection was done using a standard procedure and an immunodetection assay. Results: SE was found in one of 1081 egg samples (0.09%). The contaminated sample was offered in a supermarket under their own commercial name. Six percent of 1154 poultry meat samples were contaminated by SE and 2.3% by other Salmonella serotypes. Entrails had even higher rates with 10.2% of 370 samples harboring SE and 2,7% other serotypes. Total Salmonella sp. isolates and SE isolates declined during 1999. Nine SE phagotypes were identified, predominating types 4 and 7. Conclusions: Eggs and other avian products are contaminated by different SE phagotypes and other Salmonella serotypes, implicating a risk for the consumers (Rev Med Chile 2000; 128: 1075-83).

Emergencia de infecciones por Enterococcus sp resistente a vancomicina en un hospital universitario en Chile

Emergency of vancomycin-resistant Enterococcus infections in a teaching hospital in Chile An active surveillance of vancomycin-resistant enterococci (VRE) intestinal colonization in selected group of patients has been developed in Chile since year 2000. Nevertheless, no reports of clinical cases have been published. Aim. To describe main clinical and microbiological features of patients infected by VRE in a tertiary-level teaching Hospital. Patients and methods. Intestinal and clinical samples positive to VRE were provided by laboratory, and a retrospective analysis of potential risk factors, clinical features, treatment and outcomes was performed. Study encompassed years 2001 to 2006. Main results. 23 cases of infections were identified, all cases occurring during 2005 and 2006. Incidence rate was 0.07 and 0.09 cases per 1000 occupied bed-days, respectively. The mean age was 62.0 ± 17 years. A significant proportion of patients had cancer (39.1%), recent surgical procedures (54.1%), were on dialysis (26.1%), or were using steroids (26.1%). Most patients had received 2 or more antimicrobial (87%), almost a third represented transfers from other hospitals and an additional 22% readmissions before 30 days of latest discharge. Patients were mainly hospitalized in the ICU (60.9%) but nearly 30% were associated exclusively to nephrological or onco-hematological wards. Clinical manifestations included bacteremia (30.4%), surgical site infections or abscesses (26.1%), urinary tract infections (26.1%) and others. . Three patients (13%) did not have symptoms. After identification was possible, all isolates were identified as E. faecium (82.6% of total), the rest as Enterococcus sp. Most strains showed intermediate susceptibility to vancomycin (66.7%). For 14 strains studied both with vancomycin and teicoplanin, , phenotype Van B was predominant (85.7%), followed by VanA (7.1%) and VanB/VanD type (7.1%). No molecular studies were performed. Fifteen patients (65.4%) received a surgical and/or medical treatment. A favorable response was observed in 80% of these cases. Eight patients were not treated (34.8%), in 2 cases because of a rapidly-fatal infection. The global risk-fatality ratio for VRE infections was 13% and increased to 42.9% in patients with bacteremia. Microbiological eradication was documented in 52.2%.

Encefalitis herpética: Serie clínica de 15 casos confirmados por reacción de polimerasa en cadena

Resumen La encefalitis herpetica es la causa mas frecuentede encefalitis esporadica en el mundo occidental.Para conocer las principales caracteristicas clinicasde esta enfermedad en nuestro medio, se efectuo unanalisis de casos confirmados por reaccion depolimerasa en cadena en dos hospitales universita-rios de Santiago. Un total de 15 casos pudo seridentificado con un promedio de edad de 41 anos (5-78 anos) y 80% ≥ 30 anos, el primero de ellos el ano1998. La mayor parte se presento con fiebre y com-promiso de conciencia (80% cada uno) o cefalea(67%). Las convulsiones y la focalizacion fueroninfrecuentes (≤ 15%) y solo 2 casos (13%) tuvieronademas una manifestacion herpetica extracerebral.La duracion promedio de los sintomas fue de 3,8dias. La mayor parte estuvo asociada al serotipo 1(86,7%). El 91,7% de los casos evaluados presentoalteraciones electroencefalograficas, 81,8% altera-ciones en la resonancia magnetica y solo 13,3% enla tomografia axial computarizada. La totalidad de lospacientes fue tratada con aciclovir y la letalidad fuede 13,3%, aunque el deceso en un paciente conSIDA y linfoma del SNC no pudo ser atribuido a lainfeccion herpetica. Seis pacientes (40%) presenta-ban secuelas neurologicas al momento del egreso.La muerte o alteraciones neurologicas al alta estu-vieron asociadas significativamente a un inicio deltratamiento > 3 dias desde el inicio de los sintomas.(p = 0,01 prueba bilateral de Fisher).

Accidentes de riesgo biológico entre estudiantes de carreras de la salud: Cinco años de experiencia

Los estudiantes de pregrado de las carreras de la salud estan expuestos a riesgos biologicos con agentes de transmision sanguinea. En este trabajo se reporta la experiencia acumulada con un programa integral para este tipo de accidentes y que incluye atencion gratuita las 24 horas, estudio serologico de la fuente para VIH, VHC y VHB, y entrega de anti-retrovirales post-exposicion a pacientes infectados por VIH. Desde el ano 2003 al 2007 la tasa de incidencia alcanzo una cifra de 0,9 eventos por 100 estudiantes-ano. Las exposiciones de riesgo fueron observadas solo entre estudiantes de medicina, enfermeria y obstetricia, siendo la mayor tasa en alumnos de enfermeria (RR 3,5 IC95 1,93 a 6,51). Tres alumnos estuvieron expuestos a pacientes con infeccion por VIH (l,9%o de todos los accidentes), todos ellos recibieron profilaxis, descartandose seroconversion en el seguimiento, al igual que en casos con exposicion ante VHB y VHC (0,6%o del total de accidentes). El costo del programa fue menor a US

Inmunoglobulinas en sepsis y shock séptico

2000 por 1.000 estudiantes-ano. Los estudiantes de las carreras de la salud estan expuestos a riesgos biologicos durante sus estudios y requieren de un programa de manejo, el que es posible de lograr en un pais en desarrollo.