Antonio Gutiérrez-Pizarraya

Unexpected severity of cases of influenza B infection in patients that required hospitalization during the first postpandemic wave

OBJECTIVES After the last pandemic the knowledge regarding influenza A infection has improved however, the outcomes of influenza B infection remain poorly studied. The aim of this study was to compare the features of influenza B versus influenza A(H1N1)pdm09 infections during the 2010-2011 epidemic-season. METHODS A prospective, observational-cohort of adults with laboratory-confirmed influenza infection during the 2010-2011 epidemic-season was studied RESULTS Fifty cases of influenza B and 80 of influenza A(H1N1)pdm09 infection were enrolled. Among patients with influenza B, the median age was 34 years-old (23-64), 30% pregnant, 24% obese, 34% transplant recipients and 14% with bacterial co-infection. Twenty-eight percent of patients had pneumonia with alveolar localized pattern and five (10%) died. Pneumonia was associated with delayed antiviral therapy, older age, higher Charlson score, invasive mechanical ventilation and bacterial co-infection. Obesity and pregnancy were not associated with complicated influenza B infection. The proportion of pneumonia, admission to the ICU and mortality did not differ between cases of influenza A(H1N1)pdm09 and influenza B infection. CONCLUSIONS Influenza B infection causes severe infection and it is associated with pneumonia or death, similar to influenza A(H1N1)pdm09 infection. Rapid diagnosis and early antiviral therapy are necessary for managing influenza pneumonia during epidemic periods.

Global impact of an educational antimicrobial stewardship programme on prescribing practice in a tertiary hospital centre

The misuse of antibiotics has been related to increased morbidity, mortality and bacterial resistance. The development of antimicrobial stewardship programmes (ASPs) has been encouraged by scientific societies as an essential measure. An educational, institutionally supported ASP was developed in our tertiary-care centre. Local guidelines on the management of infectious syndromes were created. Antimicrobial prescriptions were chosen arbitrarily weekly and counselling interviews by expert clinicians were carried out, using a paedagogic, non-restrictive methodology. Satisfaction with the interview was assessed using anonymous questionnaires. The appropriateness of antimicrobial prescriptions as well as consumption was assessed prospectively throughout the year. Feedback regarding the correct use of treatments was communicated to each participating department periodically. The improvement in antimicrobial prescription was included among the annual objectives linked to economic incentives in every department. A total of 1206 counselling interviews were carried out during the first year. Fifty-three per cent of antimicrobial prescriptions (176/332) were inappropriate when the programme started. The rate of inappropriate prescriptions continuously declined to 26.4% (107/405) in the fourth trimester (p <0.001; RR = 0.38; 95% CI, 0.23-0.43). Antimicrobial consumption decreased from 1150 defined daily doses (DDDs) per 1000 occupied bed-days in the first trimester to 852 DDDs in the fourth, reflecting a reduction in antimicrobial expenditures of 42%. A total of 352 satisfaction questionnaires were received and 98% described the advice as positive. In conclusion, the implementation of an education-based ASP achieved a significant improvement in all antimicrobial prescriptions in the centre and a reduction in antimicrobial consumption, even when no restrictive measures were implemented. The programme was highly accepted by all prescribers.

Epidemiologic and clinical impact of acinetobacter baumannii colonization and infection

AbstractAcinetobacter baumannii is one of the most important antibiotic-resistant nosocomial bacteria. We investigated changes in the clinical and molecular epidemiology of A. baumannii over a 10-year period. We compared the data from 2 prospective multicenter cohort studies in Spain, one performed in 2000 (183 patients) and one in 2010 (246 patients), which included consecutive patients infected or colonized by A. baumannii. Molecular typing was performed by repetitive extragenic palindromic polymerase chain reaction (REP-PCR), pulsed-field gel electrophoresis (PFGE), and multilocus sequence typing (MLST).The incidence density of A. baumannii colonization or infection increased significantly from 0.14 in 2000 to 0.52 in 2010 in medical services (p < 0.001). The number of non-nosocomial health care-associated cases increased from 1.2% to 14.2%, respectively (p < 0.001). Previous exposure to carbapenems increased in 2010 (16.9% in 2000 vs 27.3% in 2010, p = 0.03). The drugs most frequently used for definitive treatment of patients with infections were carbapenems in 2000 (45%) and colistin in 2010 (50.3%). There was molecular-typing evidence of an increase in the frequency of A. baumannii acquisition in non-intensive care unit wards in 2010 (7.6% in 2000 vs 19.2% in 2010, p = 0.01). By MSLT, the ST2 clonal group predominated and increased in 2010. This epidemic clonal group was more frequently resistant to imipenem and was associated with an increased risk of sepsis, although not with severe sepsis or mortality.Some significant changes were noted in the epidemiology of A. baumannii, which is increasingly affecting patients admitted to conventional wards and is also the cause of non-nosocomial health care-associated infections. Epidemic clones seem to combine antimicrobial resistance and the ability to spread, while maintaining their clinical virulence.

Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality

IntroductionIn patients with severe sepsis and septic shock as cause of Intensive Care Unit (ICU) admission, we analyze the impact on mortality of adequate antimicrobial therapy initiated before ICU admission.MethodsWe conducted a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock from January 2008 to September 2013. The primary end-point was in-hospital mortality. We considered two groups for comparisons: patients who received adequate antibiotic treatment before or after the admission to the ICU.ResultsA total of 926 septic patients were admitted to ICU, and 638 (68.8%) had available microbiological isolation: 444 (69.6%) received adequate empirical antimicrobial treatment prior to ICU and 194 (30.4%) after admission. Global hospital mortality in patients that received treatment before ICU admission, between 0-6h ICU, 6–12h ICU, 12–24h ICU and after 24 hours since ICU admission were 31.3, 53.2, 57.1, 50 and 50.8% (p<0.001). The multivariate analysis showed that urinary focus (odds ratio (OR) 0.20; 0.09–0.42; p<0.001) and adequate treatment prior to ICU admission (OR 0.37; 0.24–0.56; p<0.001) were protective factors whereas APACHE II score (OR 1.10; 1.07–1.14; p<0.001), septic shock (OR 2.47; 1.57–3.87; p<0.001), respiratory source (OR 1.91; 1.12–3.21; p=0.016), cirrhosis (OR 3.74; 1.60–8.76; p=0.002) and malignancy (OR 1.65; 1.02–2.70; p=0.042) were variables independently associated with in-hospital mortality. Adequate treatment prior to ICU was a protective factor for mortality in patients with severe sepsis (n=236) or in septic shock (n=402).ConclusionsThe administration of adequate antimicrobial therapy before ICU admission is decisive for the survival of patients with severe sepsis and septic shock. Our efforts should be directed to assure the correct administration antibiotics before ICU admission in patients with sepsis.

Mortality and hospital stay related to coagulase-negative Staphylococci bacteremia in non-critical patients

OBJECTIVES To describe the morbidity and mortality related to coagulase-negative Staphylococci (CNS) bacteremia in non-critical patients. METHODS Prospective, matched case-control study nested in a cohort. Patients with CNS bacteremia and no other isolate in blood cultures during their admission were defined as cases. Each case was matched by age, sex and area of hospitalization to one control. A 30-day follow-up was performed. Mortality and hospital stay were defined as endpoints. RESULTS 105 cases and 105 controls were included. All cases carried intravascular catheters at the time of inclusion. Cases presented higher mortality compared to controls (14.3% vs. 4.8%), although this association was not independent in a multivariate analysis (p = 0.11). CNS bacteremia was independently associated with longer hospital stay (mean 12 vs. 8.5 days, p = 0.008). Moreover, when patients with CNS bacteremia were specifically analyzed, the persistence of fever (p = 0.005) and inappropriate empirical treatment (p = 0.04) were independently related to mortality. CONCLUSION We did not observe increased mortality attributable to CNS bacteremia, although it was associated with longer hospitalizations. Early appropriate empirical antibiotic therapy pending blood culture results might improve the outcome of patients with CNS bacteremia. Close follow-up is recommended if fever persists beyond 72 h.

Epidemiology, Clinical Features, and Prognosis of Elderly Adults with Severe Forms of Influenza A (H1N1)

To examine epidemiological and clinical data of individuals aged 65 and older with influenza virus A (H1N1) admitted to the intensive care unit (ICU) and to identify independent predictors of ICU mortality.

Long-Term Impact of an Educational Antimicrobial Stewardship Program on Hospital-Acquired Candidemia and Multidrug-Resistant Bloodstream Infections: A Quasi-Experimental Study of Interrupted Time-Series Analysis

Background The global crisis of bacterial resistance urges the scientific community to implement intervention programs in healthcare facilities to promote an appropriate use of antibiotics. However, the clinical benefits or the impact on resistance of these interventions has not been definitively proved. Methods We designed a quasi-experimental intervention study with an interrupted time-series analysis. A multidisciplinary team conducted a multifaceted educational intervention in our tertiary-care hospital over a 5-year period. The main activity of the program consisted of peer-to-peer educational interviews between counselors and prescribers from all departments to reinforce the principles of the proper use of antibiotics. We assessed antibiotic consumption, incidence density of Candida and multidrug-resistant (MDR) bacteria bloodstream infections (BSIs) and their crude death rate per 1000 occupied bed days (OBDs). Results A quick and intense reduction in antibiotic consumption occurred 6 months after the implementation of the intervention (change in level, -216.8 defined daily doses per 1000 OBDs; 95% confidence interval, -347.5 to -86.1), and was sustained during subsequent years (average reduction, -19,9%). In addition, the increasing trend observed in the preintervention period for the incidence density of candidemia and MDR BSI (+0.018 cases per 1000 OBDs per quarter; 95% confidence interval, -.003 to .039) reverted toward a decreasing trend of -0.130 per quarter (change in slope, -0.029; -.051 to -.008), and so did the mortality rate (change in slope, -0.015; -.021 to -.008). Conclusions This education-based antimicrobial stewardship program was effective in decreasing the incidence and mortality rate of hospital-acquired candidemia and MDR BSI through sustained reduction in antibiotic use.

Tratamiento antibiótico de los pacientes con sepsis en los servicios de urgencias: acertar desde el principio

nfections.10 When we consider that most Salmonella infections re transmitted by foods, the implementation of a specific surveilance by a foodborne diseases network such as those in the U.S. 7. Vico JP, Rol I, Garrido V, San Román B, Grilló MJ, Mainer-Jaime RC. Salmonellosis in finishing pigs in Spain. Prevalence, antimicrobial agent susceptibilities, and risk factor analysis. J Food Prot. 2011;74:1070–8. 8. Bellido-Blasco JB, González-Cano JM, Galiano-Arlandis JV, Herrero-Carot C, nd other countries could usefully to increase detection, control, nd prevention of Salmonella and other etiologic agents of FO.9

Clinical characteristics, evolution, and treatment-related risk factors for mortality among immunosuppressed patients with influenza A (H1N1) virus admitted to the intensive care unit

Purpose: Information about immunocompromised patients infected with influenza A (H1N1) virus and requiring admission to the ICU is lacking. Our objective was to know the clinical characteristics of these patients and to identify treatment‐related variables associated with mortality. Material and methods: A prospective multicenter observational cohort study was based on data from a Spanish registry (2009–2015) collected by 148 Spanish ICUs. All patients admitted to the ICU with the diagnosis of influenza A (H1N1) virus infection were included. Immunosuppression was clearly defined. Factors associated with mortality in immunocompromised patients were assessed by conventional logistic regression analysis and by a propensity score (PS) adjusted‐multivariable analysis. Results: Of 1899 patients with influenza A (H1N1) infection, 238 (12.5%) were classified as immunocompromised. Mortality was significantly higher in immunosuppressed patients. Four variables independently associated with mortality were identified: SOFA score, need of vasopressor, use of corticosteroids, and acute renal failure, AKIN 3 stage. In the PS‐adjusted model, corticosteroid therapy remained as an independent factor associated with increased mortality (OR 2.25;95%CI, 1.15–4.38;p = 0.017). In the subgroup of hematological patients (n = 141), corticosteroid therapy was also associated with increased mortality (OR 3.12; 95%CI, 1.32–7.41; p = 0.010). Conclusion: Immunocompromised individuals with influenza A (H1N1) admitted to the ICU have a poor outcome. In this population, the use of corticosteroids is strongly discouraged.

Time to positivity of blood cultures in patients with bloodstream infections: A useful prognostic tool

OBJECTIVE The time to positivity (TTP) of blood cultures in patients with bloodstream infections (BSIs) has been considered to be a possible prognostic tool for some bacterial species. However, notable differences have been found between sampling designs and statistical methods in published studies to date, which makes it difficult to compare results or to derive reliable conclusions. Our objective was to evaluate the clinical and microbiological implications of TTP among patients with BSI caused by the most common pathogens. METHODS A total of 361 episodes of BSI were reported for 332 patients. The survival of the entire cohort was measured from the time of blood culture sampling. In order to compare our results with those of previous studies, TTP was divided in three different groups based on log rank (short TTP <12h; medium TTP ≥12h to ≤27h, and long TTP >27h). Cox proportional hazard models were used to calculate crude and adjusted hazard ratios (HR). RESULTS The Cox proportional hazard model revealed that TTP is an independent predictor of mortality (HR=1.00, p=0.031) in patients with BSIs. A higher mortality was found in the group of patients with the shortest TTP (<12h) (HR=2.100, p=0.047), as well as those with longest TTP (>27h) (HR=3.277, p=0.031). CONCLUSIONS It seems that TTP may provide a useful prognostic tool associated with a higher risk of mortality, not only in patients with shorter TTP, but also in those with longer TTP.