Arturo Artero

Prognostic factors of mortality in patients with community-acquired bloodstream infection with severe sepsis and septic shock ☆,☆☆

PURPOSE The purpose of the study was to determine the independent risk factors on mortality in patients with community-acquired severe sepsis and septic shock. METHODS A single-site prospective cohort study was carried out in a medical-surgical intensive care unit in an academic tertiary care center. One hundred twelve patients with community-acquired bloodstream infection with severe sepsis and septic shock were identified. Clinical, microbiologic, and laboratory parameters were compared between hospital survivors and hospital deaths. RESULTS One-hundred twelve patients were included. The global mortality rate was 41.9%, 44.5% in septic shock and 34.4% in severe sepsis. One or more comorbidities were present in 66% of patients. The most commonly identified bloodstream pathogens were Escherichia coli (25%) and Staphylococcus aureus (21.4%). The proportion of patients receiving inadequate antimicrobial treatment was 8.9%. By univariate analysis, age, Acute Physiology and Chronic Health Evaluation II score, at least 3 organ dysfunctions, and albumin, but neither microbiologic characteristics nor site of infection, differed significantly between survivors and nonsurvivors. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.13; 95% confidence interval, 1.06-1.21) and albumin (odds ratio, 0.34; 95% confidence interval, 0.15-0.76) were independent risk factors associated with global mortality in logistic regression analysis. CONCLUSION In addition to the severity of illness, hypoalbuminemia was identified as the most important prognostic factor in community-acquired bloodstream infection with severe sepsis and septic shock.

Influence of inadequate antimicrobial therapy on prognosis in elderly patients with severe urinary tract infections

BACKGROUND Inadequate empirical antimicrobial therapy (IEAT) in intensive care unit (ICU) is associated with adverse outcomes. However, the influence of IEAT on prognosis for elderly patients with urinary tract infection (UTI) in non-ICU settings is unknown. METHODS A retrospective cross-sectional study of elderly patients admitted to a non-ICU ward in a university hospital with a primary diagnosis of UTI over a 3-year period was done. Data relating to age, sex, background comorbidities, severity of infection, bacteremia, microorganisms isolated in urine, treatment given, length of stay and prognosis were obtained using chart review. Cases were segregated according to the adequacy of empirical antimicrobial therapy. In-hospital mortality rate was the main outcome variable evaluated. RESULTS A total of 270 patients with a mean age of 83.7years were studied. Sixty-eight percent were health-care associated infections. Seventy-nine (29.3%) cases received IEAT. IEAT was associated with previous hospitalization, urinary catheter and previous antibiotic. A Gram stain of urine with a gram-positive cocci was predictive of IEAT by multivariate analysis (OR, 6.29; 95% CI, 1.05-37.49). In-hospital mortality rate was 8.9%. IEAT (OR, 3.47; 95% CI, 1.42-8.48) was an independent risk factor for mortality along with APACHE II ≥15 (OR, 3.14; 95% CI, 1.24-7.90), dementia (OR, 3.10; 95% CI, 1.19-8.07) and neoplasia (OR, 3.49; 95% CI, 1.13-10.77). IEAT was not associated with length of stay in hospital. CONCLUSION IEAT is associated with mortality in elderly patients with UTI admitted to a non-ICU ward, suggesting that improving empirical antimicrobial therapy could have a favorable impact on prognosis.

The Adverse Effects of Estrogen and Selective Estrogen Receptor Modulators on Hemostasis and Thrombosis

Agonists of the estrogen receptor include estrogens and selective estrogen receptor modulators (SERMs). Both types of compounds increase the risk for thrombosis in the arterial and the venous tree. The magnitude of the effect is influenced by potency, which depends on the type of compound and the dose. The particulars of the process change in each territory. Atherosclerosis, which creates local inflammatory conditions, may favor thrombogenesis in arteries. A direct effect of estrogen agonists is also well endorsed at both arteries, as suggested from data with high-estrogenic contraceptives, and veins. Dose reduction has been proved to be an effective strategy, but there is debate on whether additional benefit may be attained beyond a certain threshold. Hormone therapy and SERMs exhibit a lower potency estrogenic profile, but are mainly used by older women, who have a baseline increased thrombogenic risk. When used as sole agents, estrogens substantially reduce the increased risk (venous thrombosis) or may even be neutral (coronary disease). SERMs exhibit a neutral profile for coronary disease and possibly for stroke but not for venous thrombosis.

Effect of Bacteremia in Elderly Patients With Urinary Tract Infection

Introduction The clinical effect of bacteremia on outcomes in urinary tract infection (UTI) is still debated. This study aims to examine the clinical effect of bacteremia in elderly patients with UTI requiring hospital admission. Methods This retrospective observational study recorded the clinical features, microbiology and outcomes in a Spanish cohort of patients aged ≥65 years hospitalized for UTI in whom blood cultures were performed in the emergency department. The primary outcome of the study was in‐hospital mortality. Results Of 333 patients, with a mean age of 81.6 years, 137 (41.1%) had positive blood cultures. Escherichia coli, with 223 (66.9%) cases, was the most common microorganism isolated. Independent risk factors of bacteremia were temperature >38°C, heart rate >90 bpm and inversely both Enterococcus faecalis and Pseudomonas aeruginosa. Bacteremia was not associated with the length of stay in hospital (6.96 ± 3.50 days versus 7.33 ± 5.54 days, P = 0.456). Mortality rate was 9.3% with no significant difference between bacteremic and nonbacteremic cases (8.8% and 9.7%, respectively, P = 0.773). In‐hospital mortality analyzed by logistic regression was associated with McCabe index >2 (20.5% survival versus 66.7% death, adjusted odds ratio = 6.31, 95% CI: 2.71‐14.67; P < 0.001) but not with bacteremia (41.4% survival versus 38.7% death, adjusted odds ratio = 0.99, 95% CI: 0.43‐2.29; P = 0.992). Conclusions Our study suggests that the presence or absence of bacteremia in elderly people with UTI requiring hospitalization does not have an influence on outcomes such as in‐hospital mortality or length of stay.

Epidemiology of Severe Sepsis and Septic Shock

Sepsis is defined as the combination of pathologic infection and physiological changes known collectively as the systemic inflammatory response syndrome (Martin, 2003). This response results in physiological alterations that occur at the capillary endothelial level. In the early stages, the clinical manifestations of this process are unspecific and it is often underappreciated in clinical practice. However, early recognition of this syndrome is vital to reducing mortality in sepsis. From clinical studies sepsis can be seen as a continuum of severity that begins with an infection, followed in some cases by sepsis, severe sepsis – with organ dysfunction – and septic shock. There has been a substantial increase in the incidence of sepsis during the last decades, and it appears to be rising over time, with an increasing number of deaths occurring despite a decline in overall in-hospital mortality (Bone, 1992). Advanced age, underlying comorbidities and number of organ dysfunction are factors which are consistently associated with higher mortality in severe sepsis and septic shock. In this chapter we are going to review the definitions of sepsis syndromes, the factors that have contributed to the widening of physicians’ awareness of sepsis, severe sepsis and septic shock; the incidence of severe sepsis and septic shock; the epidemiological data of patients with severe sepsis and septic shock in the emergency departments and intensive care units; the causative microorganisms, and the changes observed over recent years.

Prospective cohort study of risk factors for extended-spectrum ß-lactamase-producing Escherichia coli urinary tract infections in elderly patients admitted to hospital

Extended‐spectrum beta‐lactamase (ESBL)‐producing Escherichia coli are currently common in community‐onset infections, limiting therapeutic options. In this work we aim to identify the prevalence of and risk factors for ESBL‐producing E. coli in elderly patients with urinary tract infections (UTI) admitted to hospital.

Síndrome febril tras traumatismo abdominal cerrado

bados en anaerobiosis, de Bacteroides spp. En una serie de tres hemocultivos tomados en el momento del ingreso se aislaron dos tipos de bacilos gramnegativos anaerobios estrictos, que se identificaron como Bacteroides grupo no fragilis y Fusobacterium necrophorum, ambos resistentes a penicilina. El paciente fue tratado con metronidazol, gentamicina y cefotaxima por via endovenosa durante 5 semanas y posteriormente con metronidazol y ciprofloxacino hasta completar 3 meses de tratamiento, quedando asintomatico y obteniendose la normalizacion de las pruebas hepaticas y de la funcion renal, asi como la resolucion de las imagenes de la TAC al cabo de un ano. Se realizo estudio baritado de intestino delgado y enema opaco, no encontrandose el origen del foco septico.