Alicia Hernández-Torres

Nosocomial candidemia at a general hospital: The change of epidemiological and clinical characteristics. A comparative study of 2 cohorts (1993–1998 versus 2002–2005)

BACKGROUND Nosocomial candidemia (NC) is associated with high mortality, increased hospital stay and greater economical cost. AIMS To evaluate epidemiological and clinical aspects of 2 different cohorts of non-paediatric patients with NC. METHODS A retrospective observational and comparative study of patients with NC. Patients were identified by review of results of blood cultures from the hospital microbiology laboratory. We analysed epidemiological, clinical, microbiological and laboratory data and changes in the 2 cohorts: 1993-1998 (P1) and from 2002 to 2005 (P2). RESULTS Eighty patients were studied during P1 and 107 during P2; incidence was 9/10,000 in P1 and 15.8/10,000 admitted patients in P2 (p<0.05). Mean age was 52 years in P1 and 61 years in P2 (p<0.05); 66% and 49% NC were due to Candida albicans in P1 and P2, respectively (p<0.05); diabetes was present in 12% in P1 and in 25% in P2 (p<0.05). All of the patients had previously received at least one course of broad-spectrum antibiotics. A statistically significant difference (p<0.05) in predisposing conditions was identified in central intravenous line rate (100% in P1 and 91% in P2) and previous surgery (43% in P1 and 78% in P2). Acute severity of illness at onset and complications were more frequent in P2 (p<0.05). Mortality rate was similar in P1 and P2 (51% and 49.5%, respectively). CONCLUSIONS Frequency of NC has increased and non-albicans Candida is now more frequent than C. albicans. Although acute severity of illness at onset and complications are now more frequent, mortality remains the same.

When is coagulase-negative Staphylococcus bacteraemia clinically significant?

Abstract Background: Coagulase-negative staphylococci (CoNS) are common contaminants in blood cultures (BC). A prospective study of patients with ≥ 2 blood culture sets and at least 1 positive CoNS BC was performed to develop an algorithm to assist in determining the clinical significance of CoNS bacteraemia. Methods: A single reviewer examined the medical records of patients with CoNS bacteraemia (January–June 2010). The determination of clinical significance was made according to CDC/NHSN (US Centers for Disease Control and Prevention/National Healthcare Safety Network) criteria. To explore risk factors associated with clinical significance, a multivariate analysis was performed. The performances of various algorithms were then compared. An algorithm to assist in determining clinical significance was developed. Results: Two hundred and sixty-nine cases were included; 97 (36%) were considered clinically significant bacteraemia (CSB). Predictors of CSB in the multivariate analysis were: time to positivity < 16 h (odds ratio (OR) 4.540, 95% confidence interval (CI) 1.734–11.884), identification of Staphylococcus epidermidis (OR 4.273, 95% CI 2.124–5.593), central venous catheter (OR 4.932, 95% CI 2.467–9.858), > 2 CoNS-positive bottles from different BC sets (OR 1.957, 95% CI 1.401–2.733), and Charlson score ≥ 3 (OR 2.102, 95% CI 1.078–4.099). The algorithm with best sensitivity (62%) and specificity (93%) for determining clinical significance of CoNS included Charlson score ≥ 3, Pitt score ≥ 1, neutropenic patients, presence of central venous catheter, identification of S. epidermidis, and time to positivity < 16 h. The positive predictive value was 83% and the negative predictive value was 81% (likelihood ratio 8.87). Conclusion: The use of this algorithm could potentially reduce the misclassification of nosocomial bloodstream infections and inappropriate antibiotic treatment in patients for whom a positive CoNS does not represent a CSB.

Nosocomial candidemia at a general hospital: prognostic factors and impact of early empiric treatment on outcome (2002–2005)

OBJECTIVES To evaluate epidemiological and clinical prognosis factors related to mortality and impact of early empiric treatment on patients with nosocomial candidemia (NC). PATIENTS AND METHODS Observational study of a cohort of 107 adult patients with NC admitted at a tertiary hospital (2002-5). RESULTS In bivariate analysis, risk factors significantly associated with mortality rate (49.5%) were: age >65 years, previous steroid treatment, solid organ transplant, acute severity of illness, shock, renal failure and respiratory distress at onset, delayed or inadequate antifungal treatment, non-removal of central venous catheter and associated post-surgical bacterial sepsis or respiratory infection. In multivariate analysis, risk factor associated with mortality was acute severity of illness at onset (OR 76.9; CI 12.5-500) being early and adequate treatment (OR 11.8; CI 1.7-81.2) and early (<48h) removing of central venous catheter (OR 12.2; CI 1.9-74.9) factors associated with cure; there was no statistically significant difference between fungistatic (azoles) or fungicidal (amphotericin or caspofungin) treatment. CONCLUSIONS Acute severity of illness at onset is associated with mortality in patients with NC whereas early and adequate treatment and early removing of central venous catheter are associated with cure.

Multidrug and carbapenem-resistant Acinetobacter baumannii infections: Factors associated with mortality

Background and objective To analyse factors related to mortality and influence of antibiotic treatment on outcome in patients with nosocomial infection due to multidrug and carbapenem-resistant Acinetobacter baumannii (MDR-C AB).BACKGROUND AND OBJECTIVE To analyse factors related to mortality and influence of antibiotic treatment on outcome in patients with nosocomial infection due to multidrug and carbapenem-resistant Acinetobacter baumannii (MDR-C AB). PATIENTS AND METHODS Observational and prospective study of a cohort of adult patients with MDR-C AB infection. Data collection from clinical records was done according to a standard protocol (January 2007 through June 2008). Patients with MDR-C AB infection were identified by review of results of microbiology cultures from the hospital microbiology laboratory. Epidemiological and clinical variables and predictors of mortality were analysed. RESULTS 24 out of 101 cases were considered colonizations and 77 infections (27 bacteraemia); global mortality in infected patients was 49% (18 cases with bacteraemia and 20 with no bacteraemia). In the multivariate analysis, including the 77 cases of infection, the prognosis factors associated with mortality were age (OR 1.09; 95% CI 1.02-1.2), McCabe 1 (OR 33.98; 95% CI 4.33-266.85), bacteraemia (OR 9.89; 95% CI 1.13-86.13), inadequate empiric treatment (OR 16.7; 95% CI 2.15-129.79), and inadequate definitive treatment (OR 26.29; 95% CI 1.45-478.19). In the multivariate analysis including the 57 cases of infection with adequate definitive treatment, the prognosis factors associated with mortality were McCabe 1 (OR 24.08; 95% CI 3.67-157.96) and monotherapy versus combined treatment (OR 7.11; 95% CI 1.63-30.99). CONCLUSIONS Our cohort of patients with MDR-C AB infection is characterised by a very high mortality (49%); the severity of patients and inadequate treatment or monotherapy are statistically associated with mortality.

Bacteriemia por Escherichia coli: factores predictivos de presencia de bacterias productoras de betalactamasas de espectro extendido e influencia de la resistencia en la mortalidad de los pacientes

BACKGROUND AND OBJECTIVES To analyze predictor factors of extended-spectrum betalactamasa (ESBL)-producing E. coli and its repercussion in mortality. PATIENTS AND METHODS Observational and comparative study of a cohort of non-paediatric admitted patients with E. coli bacteraemia (EB). RESULTS 153 EB (22% ESBL-producing strains). Risk factors associated with ESBLB: previous antibiotic treatment (OR 2.61; 95% CI 1.1-6.19), severity Winston score ≤2 (OR 9.83, 95% CI 3.42-28.26) and health-related acquired infection (OR 5.35; 95% CI 1.57-18.27). Related mortality rate was 21%, being independent risk factors: cancer (OR 4.02; 95% CI 1.08-14.82), high severity of underlying disease (McCabe) (OR 7.69; 95% CI 1.96-30.09) and critical severity of illness at onset (Winston) (OR 48.89; 95% CI 11.58-206.97). Inappropriate empirical therapy was more frequent in EBSL-producing group (67%, p<0.05). CONCLUSIONS Previous antibiotic treatment, severity Winston score ≤2 and health-related acquisition are factors associated to ESBL EB. EBSL-producing strains or inadequate treatment were not associated to higher mortality. Factors statistically associated to mortality were cancer, severity of underlying diseases and critical severity of illness at onset.

What is the impact of a rapid diagnostic E-test in the treatment of patients with Gram-negative bacteraemia?

Abstract Objective: To evaluate the influence of a rapid diagnostic test (RDT) in antibiotic therapeutic decisions in non-paediatric patients with Gram-negative bacteraemia (GNB). Patients and methods: A RDT consisting of a direct antibiogram was used on blood isolates of GNB. GNB were also identified and sensitivity tests were performed according to standard criteria. Information on empirical treatment was registered (T1), as well as the antibiotic administered once the results of the RDT were available (T2). Finally, we noted the ideal antibiotic that the infectious diseases specialist (IDS) would have prescribed (T3). The decision regarding T2 was always taken by the patients physician or the physician on duty. Results: A RDT was performed for 248 patients. The most frequently isolated bacterium was Escherichia coli (13% producing extended-spectrum beta-lactamase). T1 was considered appropriate in 74% and appropriate but optimizable in 43%. T2 was considered appropriate in 95%, appropriate but optimizable in 36%, and inappropriate in 5%. The cost of the optimizable treatment (T2) was € 2210, while the cost of the ideal treatment would have been € 416; the saving in antibiotic cost of 1 day of treatment would have been € 1694. Conclusions: Treatment prescribed by a non-IDS after a RDT was inappropriate in 5% and optimizable in 36%. It is our recommendation that information provided by a RDT should be interpreted by an IDS to make the information more beneficial both economically and ‘ecologically’.

Cutaneous leishmaniasis in a patient receiving infliximab

Abstract Leishmaniasis is endemic in the Mediterranean region, and the prevalence of latent infection in this area is high. Treatment with tumour necrosis factor (TNF) antagonists represents a major breakthrough in the treatment of several inflammatory diseases, including psoriasis. Reports describing opportunistic leishmaniasis in European patients treated with TNF-α antagonist drugs are rapidly accumulating. We describe a case of cutaneous leishmaniasis in a patient treated with infliximab and corticosteroids.

Ochrobactrum Anthropi Bacteraemia: Report of Six Cases and Review of the Literature

Background: Ochrobactrum anthropi is an emerging opportunistic pathogen classically considered of low virulence. The purpose of this study is to describe the most recent cases of O. anthropi bacteraemia in our hospital, along with a brief review of the literature. Methods: we have reviewed the cases of O. anthropi registered in the database of our hospital during the last 3 years. Ochrobactrum spp. was identified by the macroscopic appearance and growth characteristics; definitive identification was performed by the commercial system Vitek-2 (Biomerieux, France). Results: We report 6 cases of bacteraemia secondary to O. anthropi infection, 5 of them occurring in immunocompromised patients; the last one was considered to be contaminated due to the lack of risk factors andthe clinical improvement without an effective treatment. Two out of 6 patients had catheter-related infection, the most common infection associated to this organism. Another patient had an O. anthropi-related biliary sepsis. Probably the most relevant cases are patients number 1 and patient number 4, suffering from a pneumonia and a transjugular intrahepatic portosystemic shunt (TIPS)-related infection respectively, two uncommon infections caused by this bacterium. Clinical response was satisfactory in all cases, except in case number 4, probably in relation to the maintenance of the TIPS. Conclusion: severe immunosuppression and association with an indwelling medical device are the main factors associated with most cases of O. anthropi bacteraemia. The most important point in the treatment is the removal of the infected device, in addition to an appropriate antibiotic treatment.

Multidrug and carbapenem-resistant Acinetobacter baumannii infections, Factors associated with mortality

Background and objective To analyse factors related to mortality and influence of antibiotic treatment on outcome in patients with nosocomial infection due to multidrug and carbapenem-resistant Acinetobacter baumannii (MDR-C AB).BACKGROUND AND OBJECTIVE To analyse factors related to mortality and influence of antibiotic treatment on outcome in patients with nosocomial infection due to multidrug and carbapenem-resistant Acinetobacter baumannii (MDR-C AB). PATIENTS AND METHODS Observational and prospective study of a cohort of adult patients with MDR-C AB infection. Data collection from clinical records was done according to a standard protocol (January 2007 through June 2008). Patients with MDR-C AB infection were identified by review of results of microbiology cultures from the hospital microbiology laboratory. Epidemiological and clinical variables and predictors of mortality were analysed. RESULTS 24 out of 101 cases were considered colonizations and 77 infections (27 bacteraemia); global mortality in infected patients was 49% (18 cases with bacteraemia and 20 with no bacteraemia). In the multivariate analysis, including the 77 cases of infection, the prognosis factors associated with mortality were age (OR 1.09; 95% CI 1.02-1.2), McCabe 1 (OR 33.98; 95% CI 4.33-266.85), bacteraemia (OR 9.89; 95% CI 1.13-86.13), inadequate empiric treatment (OR 16.7; 95% CI 2.15-129.79), and inadequate definitive treatment (OR 26.29; 95% CI 1.45-478.19). In the multivariate analysis including the 57 cases of infection with adequate definitive treatment, the prognosis factors associated with mortality were McCabe 1 (OR 24.08; 95% CI 3.67-157.96) and monotherapy versus combined treatment (OR 7.11; 95% CI 1.63-30.99). CONCLUSIONS Our cohort of patients with MDR-C AB infection is characterised by a very high mortality (49%); the severity of patients and inadequate treatment or monotherapy are statistically associated with mortality.