Joaquín Gómez

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.

Infección de prótesis articulares: epidemiología y clínica. Estudio prospectivo 1992-1999

Introduccion La infeccion protesica es una complicacion grave por los problemas diagnosticos que plantea. Objetivos Estudiar las caracteristicas epidemiologicas y clinicas de las infecciones asociadas a protesis articulares para mejorar su diagnostico y manejo. Pacientes y metodos Desde diciembre de 1992 hasta diciembre de 1999, hemos evaluado de forma prospectiva a 110 pacientes con infecciones de protesis articulares. El diagnostico se llevo a cabo siguiendo criterios clinicos, microbiologicos y radiologicos, aceptados para este tipo de estudios. Resultados Su incidencia fue del 5,1%, 110 casos de 1.400 implantes articulares insertados durante el periodo de estudio. La edad media fue de 59,6 anos (intervalo, 18-79 anos), en su mayoria mujeres, 63 (57,2%). Su localizacion mas frecuente fue la rodilla, 42 casos (38%), la cadera, 29 (26%), el hombro, 1 (1%) e implantes oseos, 38 (34%). En 29 pacientes (26,3%) se encontraron enfermedades de base, entre las que destacaba diabetes en 17 casos. Como antecedentes mas importantes figuraba el uso previo de antibioticos en 58 pacientes (51%), a expensas principalmente de ciprofloxacino. Se documentaron microbiologicamente 66 casos (60%), y se aislaron grampositivos, 58,2% y gramnegativos, 32,8%, a expensas fundamental de Staphylococcus sp. y P. aeruginosa respectivamente, encontrandose anaerobios en 9%. De todos los casos, 67 eran infecciones precoces, 25 intermedias y 18 tardias, y todos los casos presentaron dolor y signos inflamatorios. En 46 casos (41,8%) se detecto fistula con supuracion, y solo 5 casos (4,8%) fiebre. Conclusiones La infeccion es una complicacion importante tras el implante de protesis articular; esta causada, fundamentalmente, por cocos grampositivos y presenta clinicamente una mayor afectacion local que sistemica.

La neurocisticercosis en Murcia

INTRODUCTION Neurocysticercosis (NC) is the most prevalent parasitic infection in the CNS. Its frequency in our environment has increased with migratory movements. The clinical and demographic characteristics of patients with NC attended in a third level hospital in an area with a high prevalence of immigrant have been analyzed. PATIENTS AND METHODS A retrospective study was done of the patients registered by the Coding Service of Virgen de la Arrixaca Hospital (January 2996 to December 2009), analyzing all the clinical histories of patients discharged with the primary or secondary diagnosis of neurocysticercosis. The most relevant epidemiological, diagnostic and therapeutic data were analyzed. RESULTS 35 patients were included in the study. Of these, 24 were men, all coming from Latin America. The most prevalent onset was seizure episode (27 patients). The number of cases per year began to increase after 2002. Although only 21 of the cases had criteria to begin medical treatment with albendazole, it had been prescribed to 29 patients. CONCLUSION In Murcia, NC is mainly an imported disease. An increase in the annual incidence has been observed since 2002, parallel to the rise in the number of immigrants. Approximately 25% of the patients received treatment in spite of not having antiparasitic treatment indication.

Infección de implantes osteoarticulares: factores pronósticos e influencia del tratamiento antibiótico prolongado en su evolución. Estudio prospectivo, 1992-1999

Introduccion Las infecciones de los implantes osteoarticulares (IOA) son de gran importancia por su morbilidad, tendencia a mayores recidivas y elevado coste sanitario Objetivos Estudio de los factores pronosticos y la influencia del tratamiento antibiotico prolongado en su evolucion Metodos Se han estudiado de forma prospectiva 110 pacientes diagnosticados de infecciones de implantes osteoarticulares. En todos los pacientes se realizaron estudios clinicos, analiticos, microbiologicos y gammagraficos con tecnecio, galio y leucocitos marcados, efectuandose controles a los 7, 15, 30 dias del inicio y despues cada 3 meses hasta el final del tratamiento y despues cada 6 meses hasta un ano despues de su suspension. El tratamiento antibiotico inicial se realizo de acuerdo con las caracteristicas epidemiologicas segun el tipo de infeccion, modificandolo en relacion con los microorganismos aislados. La duracion del tratamiento se establecio en funcion del tipo de paciente, protesis, gravedad de la infeccion y curso evolutivo. Su evolucion se ajusto a los criterios de curacion, fallo y recidiva Resultados De los 110 casos, 63 eran mujeres y 37 varones con una edad media de 59,6 anos (limites, 18 y 79 anos). De ellos, 72 correspondian a protesis articulares (42 de rodilla, 29 de cadera y uno de hombro) y 38 a implantes oseos. El 60% de los episodios se documentaron microbiologicamente. El 60,6% estuvieron causados por cocos grampositivos con predominio del genero estafilococo, el 33,3% por bacilos gramnegativos y el 6,1% por anaerobios. Como factores pronosticos asociados a fracasos o recidivas se encontro de forma significativa la cirugia articular previa, una estancia hospitalaria previa superior a 15 dias, la presencia de diabetes, la documentacion microbiologica y el tratamiento antibiotico con cefuroxima mas rifampicina. La duracion media del tratamiento fue de 9,8 meses (limites, 2 y 17 meses). El tratamiento antibiotico fue el siguiente: 61 pacientes recibieron fluorquinolonas o cotrimoxazol mas rifampicina y 29 cefuroxima-axetilo mas rifampicina. Los restantes 20 pacientes recibieron un solo antibiotico. De los 110 casos, 91 (83%) evolucionaron hacia la curacion. Los fracasos o las recidivas se observaron en 19 enfermos (17% del total de IOA y 26,7% en relacion de las protesis articulares) que requirieron la retirada de la protesis. La tolerancia al tratamiento antibiotico prolongado fue buena Conclusion El tratamiento antibiotico prolongado, con una duracion media de 9,8 meses, influye positivamente en la mejor evolucion de los IOA

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.

EFQM Excellence Model and TQM: an empirical comparison

The EFQM Excellence Model (EEM) has been used by managers and academics as a proxy for the implementation of total quality management (TQM). However, at the present time there is no empirical evidence that shows that the systems are equivalent. This paper empirically analyses whether companies that implement the EEM as a management tool are indirectly using TQM. The results make it possible to conclude that EEM and TQM, although not the same, follow a similar path and it can be expected that a company with high scores at EEM will have high odds of being a TQM company. In addition, both systems provide a means for improving performance according to the results measured by the EEM.

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.