Elisa García-Vázquez

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.

Clinical features and outcomes of tuberculosis in transplant recipients as compared with the general population: a retrospective matched cohort study

There are no previous studies comparing tuberculosis in transplant recipients (TRs) with other hosts. We compared the characteristics and outcomes of tuberculosis in TRs and patients from the general population. Twenty-two TRs who developed tuberculosis from 1996 through 2010 at a tertiary hospital were included. Each TR was matched by age, gender and year of diagnosis with four controls selected from among non-TR non-human immunodeficiency virus patients with tuberculosis. TRs (21 patients, 96%) had more factors predisposing to tuberculosis than non-TRs (33, 38%) (p <0.001). Pulmonary tuberculosis was more common in non-TRs (77 (88%) vs. 12 TRs (55%); p 0.001); disseminated tuberculosis was more frequent in TRs (five (23%) vs. four non-TRs (5%); p 0.005). Time from clinical suspicion of tuberculosis to definitive diagnosis was longer in TRs (median of 14 days) than in non-TRs (median of 0 days) (p <0.001), and invasive procedures were more often required (12 (55%) TRs and 15 (17%) non-TRs, respectively; p 0.001). Tuberculosis was diagnosed post-mortem in three TRs (14%) and in no non-TRs (p <0.001). Rates of toxicity associated with antituberculous therapy were 38% in TRs (six patients) and 10% (seven patients) in non-TRs (p 0.014). Tuberculosis-related mortality rates in TRs and non-TRs were 18% and 6%, respectively (p 0.057). The adjusted Cox regression analysis showed that the only predictor of tuberculosis-related mortality was a higher number of organs with tuberculosis involvement (adjusted hazard ratio 8.6; 95% CI 1.2-63). In conclusion, manifestations of tuberculosis in TRs differ from those in normal hosts. Post-transplant tuberculosis resists timely diagnosis, and is associated with a higher risk of death before a diagnosis can be made.

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.

Estudio comparativo de pacientes con bacteriemia por Staphylococcus aureus sensible a la meticilina frente a S. aureus resistente a la meticilina: epidemiología y factores pronósticos

Fundamento y objetivo: Hay controversia sobre la influencia de la resistencia a la meticilina en el pronostico de los pacientes con bacteriemia por Staphylococcus aureus. En este trabajo, analizamos los patrones clinicos y los factores pronosticos que se relacionan con el desarrollo de complicaciones y la mortalidad en pacientes con bacteriemia por S. aureus y valoramos la influencia de la resistencia a la meticilina (S. aureus sensible a la meticlina [SASM] frente a S. aureus resistente a la meticilina [SARM]). Pacientes y metodo: Estudio prospectivo y comparativo de 213 pacientes con bacteriemia por S. aureus. Resultados: Del total de pacientes con bacteriemia, 131 (61,5%) correspondian a SASM y 82 (38,5%) a SAMR. Se asociaron a SARM la adquisicion nosocomial de la infeccion, la presencia de una enfermedad de base rapidamente fatal y ciertos factores predisponentes (diabetes mellitus, utilizacion de cateteres vasculares, estancia previa en unidades de cuidados intensivos y uso previo de antibioticos). Los pacientes con bacteriemia por SARM presentaron mayor gravedad clinica y desarrollaron complicaciones con mas frecuencia que los pacientes con bacteriemia por SASM. La mortalidad de los casos con bacteriemia por SARM fue del 42,6%, mientras que en la de SASM fue del 16% (p < 0,05). En el analisis multivariado, del total de casos de bacteriemia por S. aureus, las variables que se asociaron a un fracaso terapeutico mayor fueron la gravedad de la enfermedad de base, una situacion clinica inicial critica-mala y el tratamiento empirico no adecuado; la resistencia a la meticilina no se asocio a mas mortalidad. Conclusiones: En los pacientes con bacteriemia por S. aureus, la resistencia a la meticilina no se asocia a una mayor mortalidad cuando se hace un analisis ajustado por otros factores clinicos/pronosticos. La gravedad de la enfermedad de base, la situacion clinica inicial critica-mala y el tratamiento empirico no adecuado son los factores pronosticos relacionados con el fracaso terapeutico en los pacientes con bacteriemia por S. aureus

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.

Abscesos cerebrales. Experiencia de 30 años

Fundamento y objetivo: Se ha realizado un estudio de las caracteristicas epidemiologicas y clini-cas de los pacientes con absceso cerebral (AC), y de los cambios que han tenido en los ultimos 30 anos. Pacientes y metodo: Estudio observacional de una cohorte de pacientes adultos con AC ingresados en un hospital de 944 camas. Los pacientes se evaluaron segun protocolo de estudio. Analizamos las caracteristicas epidemiologicas, clinicas y microbiologicas de los pacientes con AC, la localizacion y evolucion de los AC, en un periodo de 30 anos dividido en 2 mitades: 1976-1989 (P1) y 1990-2005 (P2). Resultados: Se valoro a 108 pacientes con AC (66 en P1 y 42 en P2), con una edad media de 45 anos (extremos: 12-86). Tenian mas de 40 anos de edad el 42,4% de los pacientes en P1 y el 71,4% en P2 (p < 0,05). La incidencia anual fue de 4-5 y 2-3 casos por 106 habitantes/ano en P1 y P2, respectivamente. El origen primario del AC se identifico en un 86% de los casos, con diferencias estadisticamente significativas entre ambos periodos en el foco (otitis media: el 18,2 frente al 2,4%; infeccion dental: el 3 frente al 16,7%; traumatismo craneoencefalico: el 16,7 frente al 0%; tras neurocirugia: el 15,1 frente al 21,4%, en P1 y P2, respectivamente). Hubo confirmacion microbiologica en un 76% (sin diferencias significativas entre P1 y P2). En cuanto a las caracteristicas clinicas, hubo diferencias significativas entre P1 y P2 en la alteracion del nivel de conciencia (el 10,6 frente al 0%), vomitos (el 37,9 frente al 21,4%) y deficits neurologicos focales (el 37,9 frente al 71,4%). No hubo diferencias en otras variables epidemiologicas, clinicas, radiologicas, microbiologicas o en el pronostico (mortalidad) de los pacientes entre P1 y P2. Conclusiones: A pesar de la menor incidencia de AC en P2 y de ciertas diferencias epidemiologicas y clinicas entre ambos periodos, la mortalidad y el porcentaje de recidivas en pacientes con AC no ha cambiado significativamente en los ultimos 30 anos.

Simple criteria to assess mortality in patients with community-acquired pneumonia

BACKGROUND AND OBJECTIVES The Pneumonia Patient Outcomes Research Team (PORT) developed a prediction rule to identify patients with community-acquired pneumonia (CAP) who are at risk for death and other adverse outcomes. Simpler criteria are needed to evaluate risk of mortality in CAP. PATIENTS AND METHODS Observational study of patients with CAP admitted to a tertiary care university hospital. Epidemiological, clinical, radiological and laboratory data associated with mortality were analysed. RESULTS A cohort of 211 patients with CAP was studied. Severity distribution according to PORT score was 12.3%, 15.6%, 19%, 35.5% and 17.5% in groups I, II, III, IV and V, respectively; mean age was 63 years (range, 13 to 100 years); in 43.6% age was < 65 years; 61.5% patients had > or = 1 underlying disease (congestive heart failure in 33.6% and chronic lung disease in 29.9%). Mortality rate was 0% in groups I-II, 2.5% in group III, 5.3% in group IV and 27% in group V. All variables considered in PORT-score were included in a mortality predicting model; factors significantly associated with death were: altered mental status, respiratory rate > or = 30/min, pH < 7.35, glucose > or = 250 mg/dl and age > 65 years; 99% of patients who had none of these abnormalities survived. CONCLUSIONS Simpler criteria to assess mortality in CAP were identified. Non-existence of altered mental status, respiratory rate > or = 30/min, pH < 7.35, glucose > or = 250 mg/dl and age > 65 years predicted a non-fatal outcome in 99% of patients. These clinical or laboratory findings should be considered as mortality predictors, can be used as severity adjustment measure and may help physicians make more rational decisions about hospitalization in CAP.

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’.