Armando Blanco

Usefulness of the "Candida score" for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: a prospective multicenter study.

Objective:To assess the usefulness of the “Candida score” (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point. Design:Prospective, cohort, observational study. Setting:Thirty-six medical-surgical intensive care units of Spain, Argentina, and France. Patients:A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007. Measurements and Main Results:Clinical data, surveillance cultures for fungal growth, and serum levels of (1–3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition ×1, plus surgery ×1, plus multifocal Candida colonization ×1, plus severe sepsis ×2. A CS ≥3 accurately selected patients at high risk for IC. The colonization index was registered if ≥0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06–3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p ≤ 0.001). The area under the receiver operating characteristic curve for CS was 0.774 (95% CI 0.715–0.832) compared with 0.633 (95% CI 0.557–0.709) for CI. (1–3)-Beta-d-glucan was also an independent predictor of IC (odds ratio 1.004, 95% CI 1.0–1.007). The relative risk for developing IC in colonized patients without antifungal treatment was 6.83 (95% CI 3.81–12.45). Conclusions:In this cohort of colonized patients staying >7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.

Multidrug-resistant Acinetobacter meningitis in neurosurgical patients with intraventricular catheters: assessment of different treatments

BACKGROUND The treatment of multidrug-resistant Acinetobacter baumannii meningitis is a serious therapeutic problem due to the limited penetration of antibiotics into the CSF. We describe the clinical features and the outcome of a group of patients with nosocomial neurosurgical meningitis treated with different therapeutic options. METHODS All patients with nosocomial post-surgical meningitis due to A. baumannii diagnosed between 1990 and 2004 were retrospectively reviewed. RESULTS During the period of study, 51 cases of this nosocomial infection were identified. Twenty-seven patients were treated with intravenous (iv) monotherapy: carbapenems (21 cases), ampicillin/sulbactam (4 cases) and other antibiotics (2 cases). Four patients were treated with iv combination therapy. Nineteen patients were treated with iv and intrathecal regimens: colistin by both routes (8 cases), carbapenems plus iv and intrathecal (4 cases) or only intrathecal (5 cases) aminoglycosides, and others (2 cases). Seventeen patients died due to the infection. One patient died without treatment. The mean (SD) duration of therapy was 17.4 (8.3) days (range 3-44). Although no patients treated with colistin died, we did not observe statistically significant differences in the mortality among the groups with different treatments. CONCLUSIONS Nosocomial Acinetobacter meningitis has a high mortality. Combined therapy with iv and intrathecal colistin is a useful and safe option in the treatment of nosocomial Acinetobacter meningitis.

Epidemiología e impacto de las infecciones nosocomiales

Nosocomial infections are one of the most important problems occurring in Intensive Care Units. For this reason, the epidemiology and impact of these infections on critical patients must be known. Based on the data from the ENVIN-UCI study, the rates and etiology of the main nosocomial infections, such as ventilator-associated pneumonia, urinary tract infection and primary and secondary bloodstream infection, have been described. A review of the literature regarding the impact of different nosocomial infections on critically ill patients, particularly those caused by multidrug-resistant bacteria, was also performed.

Puesta al día en medicina intensiva/enfermo crítico con infección graveEpidemiología e impacto de las infecciones nosocomialesEpidemiology and impact of nosocomial infections

Nosocomial infections are one of the most important problems occurring in Intensive Care Units. For this reason, the epidemiology and impact of these infections on critical patients must be known. Based on the data from the ENVIN-UCI study, the rates and etiology of the main nosocomial infections, such as ventilator-associated pneumonia, urinary tract infection and primary and secondary bloodstream infection, have been described. A review of the literature regarding the impact of different nosocomial infections on critically ill patients, particularly those caused by multidrug-resistant bacteria, was also performed.

Evolution over a 15-year period of clinical characteristics and outcomes of critically ill patients with community-acquired bacteremia.

Objective:In recent years, outcomes for critically ill patients with severe sepsis have improved; however, no data have been reported about the outcome of patients admitted for community-acquired bacteremia. We aimed to analyze the changes in the prevalence, characteristics, and outcome of critically ill patients with community-acquired bacteremia over the past 15 yrs. Design:A secondary analysis of prospective cohort studies in critically ill patients in three annual periods (1993, 1998, and 2007). Setting:Forty-seven ICUs at secondary and tertiary care hospitals. Patients:All adults admitted to the participating ICUs with at least one true-positive blood culture finding within the first 48 hrs of admission. Interventions:None. Measurements and Main Results:A total of 829 patients was diagnosed with community-acquired bacteremia during the study periods (148, 196, and 485 in the three periods). The prevalence density rate of community-acquired bacteremia increased from nine per 1000 ICU admissions in 1993 to 24.4 episodes per 1,000 ICU admissions in 2007 (p < 0.001). The prevalence of septic shock also increased from 4.6 episodes/1,000 admissions in 1993 to 14.6 episodes/1,000 admissions in 2007 (p < 0.001). Patients with community-acquired bacteremia were significantly older and had more comorbidities. No significant differences were observed in the presence of Gram-positive and Gram-negative micro-organisms among the three study periods. Mortality related to community-acquired bacteremia decreased over the three study periods: 42%, 32.2%, and 22.9% in 1993, 1998, and 2007, respectively (p < 0.01). The occurrence of septic shock and the number of comorbidities were independently associated with worse outcome. Appropriate antibiotic therapy and development of community-acquired bacteremia in 1998 and 2007 were independently associated with better survival. Conclusions:The prevalence of community-acquired bacteremia in ICU patients has increased. Despite a higher percentage of more severe and older patients, the mortality associated with community-acquired bacteremia decreased. Improved management of severe sepsis might explain the improvements in outcomes.

Health-care-associated bloodstream infections at admission to the ICU.

BACKGROUND Infections occurring among outpatients having recent contact with the health-care system have been recently classified as health-care-associated infections to distinguish them from hospital- and community-acquired infections. Patients with bloodstream infections (BSIs) were studied to assess health-care-associated infections at admission in the ICU. METHODS This work was a multicenter, prospective, observational study of all adult patients with BSI at ICU admission at 27 Spanish hospitals and one Argentine hospital. Cases of BSI were classified as community-acquired BSI (CAB), health-care-associated BSI (HCAB), or hospital-acquired BSI (HAB), and their characteristics were compared. RESULTS Of 726 BSIs, 343 (47.2%) were CABs, 252 (34.7%) were HABs, and 131 (18.0%) were HCABs. Potentially antibiotic-resistant pathogens were more frequently isolated in HABs (34.8%) and HCABs (27.6%) than in CABs (10.3%) (P < .001). Logistic regression analysis revealed that HABs (OR, 4.6; 95% CI, 2.9-7.3), HCABs (OR, 3.1; 95% CI, 1.8-5.4), and BSIs of unknown origin (OR, 1.7; 95% CI, 1.0-2.8) were independently associated with the isolation of potentially antibiotic-resistant pathogens. The incidence of inappropriate treatment was significantly higher in HABs (OR, 3.4; 95% CI, 2.1-5.3) and in HCABs (OR, 1.8; 95% CI, 1.0-3.2) than in CABs. CONCLUSIONS One in five BSIs diagnosed at ICU admission is health-care-associated. The incidence of potentially drug-resistant pathogens in HCABs is more similar to that of HABs, and they should be treated as such until culture data are available.

Estudio comparativo de la meningitis posquirúrgica por Staphylococcus aureus sensible y resistente a meticilina

Fundamento y objetivo En los ultimos anos se ha descrito con frecuencia creciente casos de meningitis producidas por cepas de Staphylococcus aureus resistentes a meticilina (SARM). Se estudian las caracteristicas diferenciales tanto clinicas como pronosticas de los pacientes diagnosticados de meningitis posquirurgicas debidas a SARM y las debidas a Staphylococcus aureus sensibles a meticilina (SASM). Pacientes y metodos Estudio retrospectivo, de 1992 a 2002, de 25 episodios de meningitis nosocomial posquirurgica por Staphylococcus aureus, de los que 13 fueron por SARM. Resultados Las enfermedades subyacentes mas frecuentemente diagnosticadas fueron la hemorragia cerebral (el 50% de los pacientes con SARM y el 46% de los pacientes con SASM) y las neoplasias (el 53% de los pacientes con SARM y el 33% de los pacientes con SASM). En 11 enfermos se recogia el antecedente de tratamiento antibiotico previo (6 de ellos con infeccion por SARM). Trece de los pacientes eran portadores de cateteres intraventriculares (8 con infecciones por SARM), 5 portaban una derivacion ventriculoperitoneal (4 con infecciones por SASM), otros 5 casos presentaban una fistula de liquido cefalorraquideo (4 con infecciones por SARM) y 1 paciente con infeccion por SASM tenia un cateter epidural. En 15 casos se produjo la curacion (7 con SARM), 1 enfermo de cada grupo recidivo y 8 fallecieron a consecuencia directa de la infeccion (el 27% de los pacientes con SASM y el 38% de los enfermos con SARM). Conclusiones La presencia de resistencia a la meticilina no parece empeorar el pronostico de los pacientes con meningitis posquirurgica por Staphylococcus aureus. Aunque la vancomicina permanece como tratamiento de eleccion, es posible que nuevos antibioticos de reciente aparicion cambien en el futuro el tratamiento de esta entidad.

Meningitis postquirúrgica por Acinetobacter baumannii: estudio de 22 casos y revisión de la literatura

Introduccion La meningitis postquirurgica por Acinetobacter baumannii se asocia a una importante morbimortalidad. Se ha relacionado con intervenciones neuroquirurgicas, cateteres intraventriculares (CI) o fistula de liquido cefalorraquideo (LCR). Por este motivo se determinaron sus caracteristicas, epidemiologia y evolucion. Metodos Se analizaron de forma retrospectiva, entre 1992-2000, 22 episodios de meningitis nosocomial postquirurgica por Acinetobacter baumannii, 20 de los cuales eran hombres con una edad media de 46 anos (rango: 16-83). Resultados Todos los enfermos estaban ingresados en la Unidad de Cuidados Intensivos. En un 50% de los pacientes se recogio el antecedente de una hemorragia intraventricular, un 36% presentaba un traumatismo craneoencefalico y el resto tenia una neoplasia. En 18 casos se considero que la puerta de entrada era el CI, en 2 un cateter epidural y en 2 una fistula de LCR. Los enfermos presentaban un cuadro indistinguible de otras meningitis, siendo la fiebre el sintoma mas frecuente (100%), Los hallazgos del LCR fueron compatibles con una meningitis bacteriana. En un caso se aislo el microorganismo en sangre. En 15 casos se produjo la curacion, 3 enfermos fallecieron a consecuencia directa de la infeccion y el resto recidivaron. La ausencia de curacion se asocio de forma significativa (p Conclusiones La meningitis postquirugica por Acinetobacter baumannii aparece con frecuencia en enfermos colonizados previamente en otras localizaciones y se favorece por la presencia de CI. La retirada del cateter es fundamental en su curacion.

Infección por enterococo en pacientes críticos ingresados en la UCI

BACKGROUND AND OBJECTIVE: To determine the frequency of infections caused by Enterococcus spp. in critically ill patients admitted to ICUs in Spain and to describe the clinical features and outcome of those patients in whom this pathogen was isolated. PATIENTS AND METHOD: Prospective, observational, multicenter study. Patients admitted to the ICUs who participated in the National Surveillance Study of Nosocomial Infections (ENVIN) from 1997 to 2001 were included. Patients were classified as infected by Enterococcus spp., infected by other pathogens, and without nosocomial infection (non-infected). RESULTS: Of 21,972 patients, 2,177 (9.9%) had acquired 3,490 nosocomial infections during their stay in the ICU. In 223 patients (10.2%), 239 episodes of infections in which one of the causative pathogen was Enterococcus spp. were identified (cumulative incidence 1.1 episodes of Enterococcus spp. infection per 100 patients). Enterococcus spp. accounted for urinary infection in 14.3% of cases and secondary bacteremia in 12.2% especially those related with abdominal infection (20%) and soft tissue infection (21.4%). Predominant species was E. faecalis in 197 isolates (82.4%). After multivariate analysis, variables significantly associated with infection caused by Enterococcus spp. included: age (odds ratio [OR]=1.13; 95% confidence interval [CI], 1.01-1.25); APACHE II score (OR=1.19; CI 95%, 1.07-1.32); and length of ICU stay (OR=1.02; CI 95%, 1.01-1.03). There were no differences in the overall ICU mortality rate between patients with Enterococcus spp. infection (31.8%) and those with infection caused by other pathogens (31.8%), although in both cases the mortality rate was significantly higher than in non-infected patients (11.1%). CONCLUSIONS: Enterococcus spp. was present in 10.2% patients with ICU-acquired infection. Infection by Enterococcus spp. mainly occurred in the form of urinary tract infection and secondary bacteremia, mainly related to abdominal and soft tissue infections. E. faecalis predominated in all foci. There were no differences in mortality between patients with Enterococcus spp. infection and patients with infection caused by other pathogens.

Terapia secuencial con medicamentos. Conversión de la vía intravenosa a la vía oral. ¿Una buena estrategia para disminuir la bacteriemia relacionada con catéter?

Los pacientes ingresados en la Unidad de Cuidados Intensivos (UCI) son habitualmente portadores de un catéter venoso central (CVC). Su cateterización puede producir complicaciones infecciosas y mecánicas; entre las infecciosas, se encuentra la bacteriemia relacionada con catéter (BRC) que es una de las infecciones nosocomiales más frecuentes1,2. Desde hace años se han puesto en marcha múltiples estrategias destinadas a disminuir su incidencia3--6. Pronovost et al.3 demostraron la posibilidad de reducir la BRC prácticamente a cero con un programa que incluía, entre otras medidas, 5 procedimientos relacionados con los catéteres: higiene de manos, barreras durante la inserción, asepsia de la piel con clorhexidina, evitar la vía femoral y retirar todos los CVC innecesarios. La tasa de BRC en España ha ido disminuyendo en los últimos años, especialmente desde la implantación del