José Barberán

Tratamiento antimicrobiano de la agudización de la EPOC: Documento de Consenso 2007

En el año 2002 miembros de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), la Sociedad Española de Quimioterapia (SEQ), la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), la Sociedad Española de Medicina General (SEMG) y la Sociedad Española de Medicina Rural y Generalista (SEMERGEN) elaboraron el Segundo Documento de Consenso sobre el uso de antimicrobianos en la agudización de la enfermedad pulmonar obstructiva crónica (EPOC)1. Cinco años después, expertos de las mismas sociedades, conscientes de la amplia difusión e interés práctico que en su momento tuvo el citado documento, se han reunido de nuevo con objeto de actualizarlo a la luz de la bibliografía médica más relevante publicada durante este período. Este Documento de Consenso 2007 incorpora nuevos conocimientos sobre la valoración que ha de darse a la purulencia del esputo en la indicación del tratamiento antibiótico y la evolución de la tasa de resistencia de los principales patógenos frente a los antimicrobianos recomendados en su momento, y recoge la experiencia obtenida en el transcurso de estos años con el empleo de las fluoroquinolonas, la nueva formulación de amoxicilina-ácido clavulánico de liberación retardada, que posibilita la administración oral de dosis elevadas de amoxicilina, y las cefalosporinas orales de tercera generación como el cefditorén, que muestran una elevada actividad intrínseca frente a cepas de neumococo resistente a penicilina.

Clinical features of invasive pulmonary aspergillosis vs. colonization in COPD patients distributed by gold stage.

OBJECTIVE To explore clinical features of invasive pulmonary aspergillosis (IPA) vs. colonization among hospitalized COPD patients. METHODS Records of COPD patients with two respiratory cultures yielding Aspergillus were retrospectively reviewed. Cases categorized as proven/probable IPA or colonization was analyzed. RESULTS 118 patients were identified: 70 (59.3%) colonized, 48 (40.7%) with IPA (42 probable, 6 proven). Higher percentage of IPA patients (vs. colonized) presented GOLD III + IV (77.1% vs. 57.1%, p = 0.025). IPA patients presented higher Charlson index (3.5 ± 2.5 vs. 2.6 ± 2.2, p = 0.027), higher rate of ICU admission (27.1% vs. 4.3%, p = 0.001) and worse prognosis (McCabe rapidly fatal category: 31.3% vs. 7.1%, p = 0.001). GOLD-I IPA patients presented risk factors other than COPD. Before hospitalization, 66.7% IPA and 28.6% colonized patients were taking steroids (p < 0.001). Antifungals were administered to 83.3% IPA and 21.4% colonized patients (p < 0.001). Mortality was higher among IPA vs. colonized patients, both in global (58.3% vs. 10.0%, p < 0.001), GOLD-I (75.0% vs. 10.0%, p = 0.041), GOLD-II (42.9% vs. 5.0%, p = 0.042) and GOLD-III patients (54.2% vs. 0.0%, p < 0.001), but not in GOLD-IV patients (69.2% vs. 31.3%, p = 0.066). CONCLUSIONS IPA should be suspected not only in GOLD-III and GOLD-IV COPD patients, with higher mortality in IPA vs. colonized patients for GOLD-II and -III COPD patients.

Guía multidisciplinar para la valoración pronóstica, diagnóstico y tratamiento de la neumonía adquirida en la comunidad.

Community-acquired pneumonia (CAP) is an infectious respiratory disease with an incidence that ranges from 3 to 8 cases per 1,000 inhabitants per year. This incidence increases with age and comorbidities. Forty per cent of CAP patients require hospitalization and around 10% of these patients are admitted in an Intensive Care Unit (ICU). Several studies have suggested that the implementation of clinical guidelines has a positive impact in the outcome of patients including mortality and length of stay. The more recent and used guidelines are those from Infectious Diseases Society of America/American Thoracic Society, published in 2007, the 2009 from the British Thoracic Society, and that from the European Respiratory Society/European Society of Clinical Microbiology and Infectious Diseases, published in 2010. In Spain, the most recently released guideline is the Sociedad Española de Neumología y Cirugía Torácica-2011 guideline. The present guidelines GNAC are designed to be used by the majority of health-care professionals that can participate in the care of CAP patients including diagnosis, decision of hospital and ICU admission, treatment and prevention. The Centro Cochrane Iberoamericano (CCIB) has participated in summarizing the previous guidelines and in the bibliography search. For each one of the following sections the panel of experts has developed a table with recommendations classified according to its evidence, strength and practical applicability using the Grading of Recommendations of Assessment Development and Evaluations (GRADE) system: 1. Epidemiology, microbiological etiology and antibiotic resistances.2. Clinical and microbiological diagnosis.3. Prognostic scales and decision of hospital admission.4. ICU admission criteria. 5. Empirical and definitive antibiotic treatment.6. Treatment failure. 7. Prevention.

High doses of daptomycin (10 mg/kg/d) plus rifampin for the treatment of staphylococcal prosthetic joint infection managed with implant retention: a comparative study.

We aimed to analyze the efficacy and safety of high doses of daptomycin (10 mg/kg/d) plus rifampin (D10 + R) for prosthetic joint infection (PJI). This was an observational retrospective multicenter study (2010-2012) including all patients with acute PJI by fluoroquinolone-resistant staphylococci managed with implant retention and D10 + R. Twenty cases were included: 2 (10%) were withdrawn due to toxicity, leaving 18 cases for efficacy evaluation: 13 (72%) women, age 79 years (range 58-90). Clinical failure was observed in 9 (50%) patients: in 5 cases, staphylococci were recovered (28% of microbiological failures); no modification of daptomycin-MIC was observed. These 18 cases were compared with 44 matched historical cases: failure rate was similar, but whereas in the historical series, failure occurred fundamentally during therapy, in the present series, it was recorded after discontinuation of antibiotics. In summary, D10 + R may be the initial treatment of choice for PJI by fluoroquinolone-resistant staphylococci managed with implant retention.

Antimicrobial Treatment of Exacerbation in Chronic Obstructive Pulmonary Disease: 2007 Consensus Statement *

In 2002, members of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), the Spanish Society of Chemotherapy (SEQ), the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of General Medicine (SEMG), and the Spanish Society of Rural and General Medicine (SEMERGEN) prepared the second consensus report on the use of antimicrobial agents in exacerbations of chronic obstructive pulmonary disease (COPD).1 Given the widespread practical interest in that consensus statement, experts from the same societies met 5 years later to prepare an updated statement in the light of literature published in the intervening period. This 2007 Consensus Statement will include new information regarding the significance of purulent sputum in the decision to prescribe antibiotic treatment and changes in the rate of resistance of the main pathogens to previously recommended antimicrobial drugs. It reports on the experience obtained in the last 5 years with the use of fluoroquinolones, the new slow-release formulation of amoxicillin-clavulanic acid, which allows oral administration of high-dose amoxicillin, and the third-generation oral cephalosporins, such as cefditoren, which have a high intrinsic activity against penicillin-resistant strains of pneumococcus.

Levofloxacin plus rifampicin conservative treatment of 25 early staphylococcal infections of osteosynthetic devices for rigid internal fixation

Therapeutic conclusions for staphylococcal implant infections treated with debridement and implant retention can only be drawn from a small series. To this aim, data from patients with implant staphylococcal infections (1998-2006) treated with debridement and implant retention were retrospectively reviewed. Infections were defined by staphylococci isolation (two or more consecutive debridement or three sinus tract discharge samples) along with clinical criteria. Patients received oral levofloxacin plus rifampicin for >or=6 weeks after the resolution of signs/symptoms and C-reactive protein normalisation. Failure was defined as lack of response or recurrence of signs/symptoms and/or sinus tract bacterial isolation during therapy or follow-up and/or implant removal. Twenty-five patients (53.2+/-20.8 years; 48% males) were included, 12 with spinal infections and 13 with limb implant infections. Diagnosis was performed from debridement material (72%) and sinus tract discharge (28%) (11 Staphylococcus aureus and 14 coagulase-negative staphylococci (CoNS)). Time from surgery to symptom onset was higher in CoNS infections compared with S. aureus infections (21.6+/-9.3 days vs. 12.6+/-5.2 days; P=0.007). Seven patients (28%) were failures, with no differences between cured patients with respect to age, sex, infection site, time from surgery to symptom onset, sinus tract diagnosis and aetiology. Longer symptom duration prior to attendance was observed in failures (5.7+/-6.2 months vs. 1.4+/-0.6 months; P=0.04). Levofloxacin plus rifampicin showed efficacy in implant infections, which was higher for short duration of symptoms.

Nationwide study on the use of intravascular catheters in internal medicine departments

BACKGROUND The use of intravascular catheters (IVCs) in intensive care units (ICUs) has been well assessed in recent years. However, a high proportion of these devices are placed in patients outside the ICU, particularly in internal medicine departments (IMDs), where data on the quality of care are scarce. AIM To assess the use and management of IVCs in IMDs in Spain. METHODS We performed a point prevalence study of all adult inpatients on 47 IMDs from hospitals of different sizes on one day in June 2013. A local co-ordinator was appointed to assess patients and collect data from each site. FINDINGS Out of the 2080 adult patients hospitalized on the study day, 1703 (81.9%) had one or more IVCs (95.4% of which were peripheral devices). Infection was detected at the insertion site in 92 catheters (5.0%); 87 patients (5.2%) had signs of sepsis, but only one case was considered to be catheter-related. The local co-ordinators estimated that 19% of the catheters in place were no longer necessary. A daily record of the need for a catheter was available in only 40.6% of cases. CONCLUSION Our study shows clear opportunities for improvement regarding catheter use and care in Spanish IMDs. Strategies similar to those applied in ICUs should be implemented in IMDs.

Repeated Aspergillus isolation in respiratory samples from non-immunocompromised patients not selected based on clinical diagnoses: colonisation or infection?

BackgroundIsolation of Aspergillus from lower respiratory samples is associated with colonisation in high percentage of cases, making it of unclear significance. This study explored factors associated with diagnosis (infection vs. colonisation), treatment (administration or not of antifungals) and prognosis (mortality) in non-transplant/non-neutropenic patients showing repeated isolation of Aspergillus from lower respiratory samples.MethodsRecords of adult patients (29 Spanish hospitals) presenting ≥2 respiratory cultures yielding Aspergillus were retrospectively reviewed and categorised as proven (histopathological confirmation) or probable aspergillosis (new respiratory signs/symptoms with suggestive chest imaging) or colonisation (symptoms not attributable to Aspergillus without dyspnoea exacerbation, bronchospasm or new infiltrates). Logistic regression models (step–wise) were performed using Aspergillosis (probable + proven), antifungal treatment and mortality as dependent variables. Significant (p < 0.001) models showing the highest R2 were considered.ResultsA total of 245 patients were identified, 139 (56.7%) with Aspergillosis. Aspergillosis was associated (R2 = 0.291) with ICU admission (OR = 2.82), congestive heart failure (OR = 2.39) and steroids pre-admission (OR = 2.19) as well as with cavitations in X-ray/CT scan (OR = 10.68), radiological worsening (OR = 5.22) and COPD exacerbations/need for O2 interaction (OR = 3.52). Antifungals were administered to 79.1% patients with Aspergillosis (100% proven, 76.8% probable) and 29.2% colonised, with 69.5% patients receiving voriconazole alone or in combination. In colonised patients, administration of antifungals was associated with ICU admission at hospitalisation (OR = 12.38). In Aspergillosis patients its administration was positively associated (R2 = 0.312) with bronchospasm (OR = 9.21) and days in ICU (OR = 1.82) and negatively with Gold III + IV (OR = 0.26), stroke (OR = 0.024) and quinolone treatment (OR = 0.29). Mortality was 78.6% in proven, 41.6% in probable and 12.3% in colonised patients, and was positively associated in Aspergillosis patients (R2 = 0.290) with radiological worsening (OR = 3.04), APACHE-II (OR = 1.09) and number of antibiotics for treatment (OR = 1.51) and negatively with species other than A. fumigatus (OR = 0.14) and aspergillar tracheobronchitis (OR = 0.27).ConclusionsAdministration of antifungals was not always closely linked to the diagnostic categorisation (colonisation vs. Aspergillosis), being negatively associated with severe COPD (GOLD III + IV) and concomitant treatment with quinolones in patients with Aspergillosis, probably due to the similarity of signs/symptoms between this entity and pulmonary bacterial infections.

Predictive model of short-term amputation during hospitalization of patients due to acute diabetic foot infections

INTRODUCTION Factors predicting short-term amputation during hospital treatment of patients admitted for acute diabetic foot infections are of interest for clinicians managing the acute episode. METHODS A retrospective clinical records analysis of 78 consecutive patients hospitalized for acute diabetic foot infections was performed to identify predictive factors for short-term amputation by comparing the data of patients who ultimately required amputation and those who did not. Clinical/epidemiological, laboratory, imaging, and treatment variables were comparatively analyzed. A logistic regression model was performed, with amputation as the dependent variable and factors showing significant differences in the bivariate analysis as independent variables. A prediction score was calculated (and validated by ROC curve analysis) using beta coefficients for significant variables in the regression analysis to predict amputation. RESULTS Of the 78 patients (70.5% with peripheral vasculopathy) included, 26 ultimately required amputation. In the bivariate analysis, white blood cell count, previous homolateral lesions, odor, lesion depth, sedimentation rate, Wagner ulcer grade, and arterial obstruction on Doppler study were significantly higher in patients ending in amputation. In the multivariate analysis, the risk of amputation was increased only by Wagner grade 4 or 5 (20-fold higher), obstruction (12.5-fold higher), and elevated sedimentation rate (6% higher per unit). Logistic regression predicted outcome in 76.9% of patients who underwent amputation and 92.3% of those who did not. CONCLUSION The score calculated using beta coefficients for significant variables in the regression model (Wagner grades 4 and 5, obstruction on Doppler, and elevated sedimentation rate for the clinical, imaging, and laboratory data, respectively) correctly predicted amputation during hospital management of acute diabetic foot infections.

[Multidisciplinary guidelines for the management of community-acquired pneumonia].

Community-acquired pneumonia (CAP) is an infectious respiratory disease with an incidence that ranges from 3 to 8 cases per 1,000 inhabitants per year. This incidence increases with age and comorbidities. Forty per cent of CAP patients require hospitalization and around 10% of these patients are admitted in an Intensive Care Unit (ICU). Several studies have suggested that the implementation of clinical guidelines has a positive impact in the outcome of patients including mortality and length of stay. The more recent and used guidelines are those from Infectious Diseases Society of America/American Thoracic Society, published in 2007, the 2009 from the British Thoracic Society, and that from the European Respiratory Society/European Society of Clinical Microbiology and Infectious Diseases, published in 2010. In Spain, the most recently released guideline is the Sociedad Española de Neumología y Cirugía Torácica-2011 guideline. The present guidelines GNAC are designed to be used by the majority of health-care professionals that can participate in the care of CAP patients including diagnosis, decision of hospital and ICU admission, treatment and prevention. The Centro Cochrane Iberoamericano (CCIB) has participated in summarizing the previous guidelines and in the bibliography search. For each one of the following sections the panel of experts has developed a table with recommendations classified according to its evidence, strength and practical applicability using the Grading of Recommendations of Assessment Development and Evaluations (GRADE) system: 1. Epidemiology, microbiological etiology and antibiotic resistances.2. Clinical and microbiological diagnosis.3. Prognostic scales and decision of hospital admission.4. ICU admission criteria. 5. Empirical and definitive antibiotic treatment.6. Treatment failure. 7. Prevention.