José Arnoby Chacón

FUNGAL PERITONITIS IN PERITONEAL DIALYSIS PATIENTS: SUCCESSFUL PROPHYLAXIS WITH FLUCONAZOLE, AS DEMONSTRATED BY PROSPECTIVE RANDOMIZED CONTROL TRIAL

♦ Objectives: To determine whether oral administration of the antifungal fluconazole during the entire period of treatment of bacterial peritonitis (BP), exit-site infection (ESI), or tunnel infection (TI) prevents later appearance of fungal peritonitis (called secondary) in patients with chronic kidney disease stage 5 in a peritoneal dialysis (PD) program. ♦ Patients and Methods: All patients treated in the PD program in RTS Ltda Sucursal Caldas, during the period 1 June 2004 to 30 October 2007 were screened. Patients that had infectious bacterial complications (BP, ESI, TI) were included in a prospective randomized trial to receive or not receive oral fluconazole (200 mg every 48 hours) throughout the time period required by the administration of therapeutic antibiotics via any route. It was evaluated whether the fungal peritonitis complication appeared within 30 – 150 days following the end of antibacterial treatment. Based on local results, the sample size necessary to obtain statistically significant results was determined to be 434 episodes of peritonitis. ♦ Results: The 434 episodes of peritonitis presented between the previously specified dates and during this same period there were 174 ESI or TI, of which only 52 received oral antibiotic treatment. Information in relation to consumption of antibiotics for purposes other than BP, ESI, and TI was not reliable and thus this variable was excluded. Among the episodes of peritonitis, 402 (92.6%) were of bacterial origin and 32 (7.3%) were mycotic, mainly Candida species [30 (93.75%)]. Of the fungal peritonitis, 14 (43.73%) were primary (without prior use of antibiotics) and 18 (56.25%) were secondary. In the group of patients that received prophylaxis with fluconazole (210 for BP and 26 for ESI or TI), only 3 occurrences of fungal peritonitis were observed within 30 – 150 days of its administration, which is opposite to the group without prophylaxis (210 for BP and 26 for ESI or TI), in which 15 occurrences of fungal peritonitis were detected. Statistical analysis of the group of patients with BP found comparisons of the proportions of those receiving fluconazole (0.92%) or not (6.45%) presented a highly significant difference in favor of prophylaxis (p = 0.0051, Z = 2.8021). Given that only 1 patient in each group with ESI or TI, with or without prophylaxis, presented the complication fungal peritonitis, it was concluded that this result was not statistically significant. During laparoscopic surgery attempting reintroduction of the peritoneal catheter, it was found that 11 patients had severe adhesions or peritoneal fibrosis leading to obliteration of the peritoneal cavity. In 19 patients, reintroduction of the catheter was possible and the patients returned to PD without consequence. ♦ Conclusion: In patients with bacterial peritonitis, administration of prophylactic oral fluconazole throughout the time they received antibiotics significantly prevented the appearance of secondary fungal peritonitis.

Validez y fiabilidad de la escala de Braden para predecir riesgo de úlceras por presión en ancianos1

Objetivo Determinar la validez predictiva y la fiabilidad de la escala de Braden para predecir el riesgo de ulceras por presion (UP) en ancianos en una institucion de referencia de tercer nivel de atencion. DiseNo Estudio de cohorte. Material y mEtodos Se tomaron los 831 pacientes sin UP al ingreso, mayores de 60 anos, hospitalizados al menos durante 72 horas en el Hospital de Caldas durante un ano, septiembre 1988-1999. Las variables demograficas y el diagnostico primario al ingreso a las salas de hospitalizacion se tomaron de la historia clinica. Se clasifico el tipo de piel, se valoro el estado funcional mediante la escala de Barthel. La version original en ingles de la escala de Braden se tradujo al espanol y se aplico a las 72 horas del ingreso y cada semana hasta tres semanas, evaluando de forma simultanea el desarrollo de UP, las cuales se estadificaron de I a IV. La sensibilidad, la especificidad, el Valor Predictivo Positivo (VPP) y el Valor Predictivo Negativo (VPN) fueron calculados para los diferentes puntajes de la Escala de Braden en las cuatro aplicaciones o hasta la evaluacion anterior a la deteccion de la primera UP. Resultados El promedio de edad fue 71,9 (DE 8), 57% eran hombres y 96,9% procedian del hogar. El puntaje en la escala de Barthel oscilo entre 0 y 100 con una media de 46,9. En cuanto a los diagnosticos al ingreso las enfermedades cardiovasculares, osteomusculares, gastrointestinales y neurologicas fueron en su orden las patologias mas frecuentes. El 8,04% de los sujetos estudiados desarrollaron UP durante el estudio, 71,6% la desarrollaron durante la primera semana, 20,8% en la segunda y 7,5% en la tercera semana. Se presentaron principalmente en sacro y en estados I y II. El rango de los puntajes en la Escala de Braden oscilo entre 6 y 23. El percentil 25 en todas las evaluaciones estuvo entre 15 y 16 puntos, y el percentil 75 en 21. Las variaciones de los puntajes entre las tres evaluaciones fueron minimas. Las Curvas Operantes de Receptor (COR) derivadas de los datos muestran que un puntaje de 16 produce un punto de corte optimo donde simultaneamente se maximiza la sensibilidad a 85,4% y la especificidad a 63,2% con un VPP de 12,5 en ese punto y un VPN de 98,6. Conclusiones Este estudio permite concluir que en ancianos hospitalizados la escala de Braden para predecir riesgo de UP es confiable y valida, con un punto de corte de 16. Ademas sugiere que se deben tener en cuenta otros factores que afectan su validez como la edad y el estado funcional.