Juan Gálvez

Ampicillin Plus Ceftriaxone Is as Effective as Ampicillin Plus Gentamicin for Treating Enterococcus faecalis Infective Endocarditis

BACKGROUND The aim of this study was to compare the effectiveness of the ampicillin plus ceftriaxone (AC) and ampicillin plus gentamicin (AG) combinations for treating Enterococcus faecalis infective endocarditis (EFIE). METHODS An observational, nonrandomized, comparative multicenter cohort study was conducted at 17 Spanish and 1 Italian hospitals. Consecutive adult patients diagnosed of EFIE were included. Outcome measurements were death during treatment and at 3 months of follow-up, adverse events requiring treatment withdrawal, treatment failure requiring a change of antimicrobials, and relapse. RESULTS A larger percentage of AC-treated patients (n = 159) had previous chronic renal failure than AG-treated patients (n = 87) (33% vs 16%, P = .004), and AC patients had a higher incidence of cancer (18% vs 7%, P = .015), transplantation (6% vs 0%, P = .040), and healthcare-acquired infection (59% vs 40%, P = .006). Between AC and AG-treated EFIE patients, there were no differences in mortality while on antimicrobial treatment (22% vs 21%, P = .81) or at 3-month follow-up (8% vs 7%, P = .72), in treatment failure requiring a change in antimicrobials (1% vs 2%, P = .54), or in relapses (3% vs 4%, P = .67). However, interruption of antibiotic treatment due to adverse events was much more frequent in AG-treated patients than in those receiving AC (25% vs 1%, P < .001), mainly due to new renal failure (≥25% increase in baseline creatinine concentration; 23% vs 0%, P < .001). CONCLUSIONS AC appears as effective as AG for treating EFIE patients and can be used with virtually no risk of renal failure and regardless of the high-level aminoglycoside resistance status of E. faecalis.

Long-Term Control of Endemic Hospital-Wide Methicillin-Resistant Staphylococcus aureus (MRSA): The Impact of Targeted Active Surveillance for MRSA in Patients and Healthcare Workers

OBJECTIVE To evaluate the long-term impact of successive interventions on rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection and MRSA bacteremia in an endemic hospital-wide situation. DESIGN Quasi-experimental, interrupted time-series analysis. The impact of the interventions was analyzed by use of segmented regression. Representative MRSA isolates were typed by use of pulsed-field gel electrophoresis. SETTING A 950-bed teaching hospital in Seville, Spain. PATIENTS All patients admitted to the hospital during the period from 1995 through 2008. METHODS Three successive interventions were studied: (1) contact precautions, with no active surveillance for MRSA; (2) targeted active surveillance for MRSA in patients and healthcare workers in specific wards, prioritized according to clinical epidemiology data; and (3) targeted active surveillance for MRSA in patients admitted from other medical centers. RESULTS Neither the preintervention rate of MRSA colonization or infection (0.56 cases per 1,000 patient-days [95% confidence interval {CI}, 0.49-0.62 cases per 1,000 patient-days]) nor the slope for the rate of MRSA colonization or infection changed significantly after the first intervention. The rate decreased significantly to 0.28 cases per 1,000 patient-days (95% CI, 0.17-0.40 cases per 1,000 patient-days) after the second intervention and to 0.07 cases per 1,000 patient-days (95% CI, 0.06-0.08 cases per 1,000 patient-days) after the third intervention, and the rate remained at a similar level for 8 years. The MRSA bacteremia rate decreased by 80%, whereas the rate of bacteremia due to methicillin-susceptible S. aureus did not change. Eighty-three percent of the MRSA isolates identified were clonally related. All MRSA isolates obtained from healthcare workers were clonally related to those recovered from patients who were in their care. CONCLUSION Our data indicate that long-term control of endemic MRSA is feasible in tertiary care centers. The use of targeted active surveillance for MRSA in patients and healthcare workers in specific wards (identified by means of analysis of clinical epidemiology data) and the use of decolonization were key to the success of the program.

Bacteriemias por Acinetobacter baumannii: características clínicas y pronósticas

Objetivo Analisis de la incidencia, caracteristicas clinicas y pronostico de las bacteriemias por Acinetobacter baumannii Metodos Estudio prospectivo de la cohorte de bacteriemias por A. baumannii detectadas entre enero de 1995 y diciembre de 1998. A. baumannii se identifico segun las recomendaciones mas recientes Resultados Se incluyeron 133 bacteriemias, todas de adquisicion nosocomial. La densidad de incidencia fue de 2,02 episodios/10.000 pacientes-dia y descendio a 0,40 episodios/10.000 pacientes-dia con la aplicacion del programa de control. El 70% de los pacientes estaba o habia estado en la unidad de cuidados intensivos. El 85% padecia enfermedades cronicas concomitantes y el 62% un indice de gravedad de Hilf superior a 4. El 78% de las cepas eran multirresistentes y el 28% resistentes a imipenem. La mortalidad atribuible fue del 25,6%. El analisis multivariado mostro que el tratamiento antibiotico inapropiado, el shock septico y un mayor indice de gravedad de Hilf fueron factores independientes de mal pronostico Conclusion La bacteriemia por A. baumannii afecta fundamentalmente a pacientes graves sometidos a multiples procedimientos invasivos, en los que la morbimortalidad puede ser elevada. El tratamiento antimicrobiano inadecuado se asocio, entre otros factores, a un peor pronostico

A note on the use of sodium hydroxide treated straw pellets in diets for growing rabbits

The effects of the inclusion of increasing quantities of cereal straw treated with sodium hydroxide in the diet of rabbits weie studied on 68 animals, both males and females, of the Spanish Giant and New Zealand × Spanish Giant breeds, weaned at different weights. The nitrogen and fibre digestibilities, the overall growth rate (from weaning to 2·25 kg) and the partial growth rate (from weaning to 2 weeks after weaning) increased linearly, while the feed conversion rate decreased when the content of treated straw in the feed was raised. The overall growth rate for males was significantly higher ( P P P P P P P

Endocarditis en válvulas nativas izquierdas por estafilococos coagulasa negativos: una entidad en alza

OBJECTIVES: To describe the epidemiological, clinical, and prognostic characteristics of patients with left-sided native valve endocarditis (LNVE) caused by coagulase-negative staphylococci (CoNS). PATIENTS AND METHOD: Prospective multicenter study of endocarditis cases reported in the Andalusian Cohort for the Study of Cardiovascular Infections between 1984 and 2005. RESULTS: Among 470 cases of LNVE, 39 (8.3%) were caused by CoNS, a number indicating a 30% increase in the incidence of this infection over the last decade. The mean age of affected patients was 58.32 +/- 15 years and 27 (69.2%) were men. Twenty-one patients (53.8%) had previous known valve disease and half the episodes were considered nosocomial (90% of them from vascular procedures). Median time interval from the onset of symptoms to diagnosis was 14 days (range: 1-120). Renal failure (21 cases, 53.8%), intracardiac damage (11 cases, 28.2%), and central nervous system involvement (10 cases, 25.6%) were the most frequent complications. There were only 3 cases (7.7%) of septic shock. Surgery was performed in 18 patients (46.2%). Nine patients (23.1%) died, overall. Factors associated with higher mortality in the univariate analysis were acute renal failure (P = 0.023), left-sided ventricular failure (P = 0.047), and time prior to diagnosis less than 21 days (P = 0.018). As compared to LNVE due to other microorganisms, the patients were older (P = 0.018), had experienced previous nosocomial manipulation as the source of bacteremia (P < 0.001), and developed acute renal failure more frequently (P = 0.001). Mortality of LNVE due to CoNS was lower than mortality in Staphylococcus aureus infection, but higher than in Streptococcus viridans infection. CONCLUSIONS: Left-sided native valve endocarditis due to CoNS is now increasing because of the ageing of the population. This implies more frequent invasive procedures (mainly vascular) as a consequence of the concomitant disease. Nonetheless, the mortality associated with LNVE due to CoNS does not seem to be greater than infection caused by other pathogens.OBJECTIVES To describe the epidemiological, clinical, and prognostic characteristics of patients with left-sided native valve endocarditis (LNVE) caused by coagulase-negative staphylococci (CoNS). PATIENTS AND METHOD Prospective multicenter study of endocarditis cases reported in the Andalusian Cohort for the Study of Cardiovascular Infections between 1984 and 2005. RESULTS Among 470 cases of LNVE, 39 (8.3%) were caused by CoNS, a number indicating a 30% increase in the incidence of this infection over the last decade. The mean age of affected patients was 58.32 +/- 15 years and 27 (69.2%) were men. Twenty-one patients (53.8%) had previous known valve disease and half the episodes were considered nosocomial (90% of them from vascular procedures). Median time interval from the onset of symptoms to diagnosis was 14 days (range: 1-120). Renal failure (21 cases, 53.8%), intracardiac damage (11 cases, 28.2%), and central nervous system involvement (10 cases, 25.6%) were the most frequent complications. There were only 3 cases (7.7%) of septic shock. Surgery was performed in 18 patients (46.2%). Nine patients (23.1%) died, overall. Factors associated with higher mortality in the univariate analysis were acute renal failure (P = 0.023), left-sided ventricular failure (P = 0.047), and time prior to diagnosis less than 21 days (P = 0.018). As compared to LNVE due to other microorganisms, the patients were older (P = 0.018), had experienced previous nosocomial manipulation as the source of bacteremia (P < 0.001), and developed acute renal failure more frequently (P = 0.001). Mortality of LNVE due to CoNS was lower than mortality in Staphylococcus aureus infection, but higher than in Streptococcus viridans infection. CONCLUSIONS Left-sided native valve endocarditis due to CoNS is now increasing because of the ageing of the population. This implies more frequent invasive procedures (mainly vascular) as a consequence of the concomitant disease. Nonetheless, the mortality associated with LNVE due to CoNS does not seem to be greater than infection caused by other pathogens.

A comprehensive surveillance, control and management programme for Clostridium difficile infection

The audit showed that simple side-room guidelines such as those developed at St George’s can help to improve the use of limited single rooms and ensure that the highest priority patients are isolated. It is noteworthy that MRSA carriage has a lower priority than many other indications, so that most MRSA carriers remain on the open ward. As was shown by the small number of inappropriate indications, the guidelines need to be combined with active management of single rooms if they are to be effective. The key element of this is daily review of single-room use by senior ward sisters, to ensure that priorities are continually reassessed as clinical conditions change. In the long term, as newer facilities are built, the problem will eventually decrease; but for the foreseeable future, guidance such as this will still be needed in the UK.

Broadened Definition of Health Care–Associated Infective Endocarditis and Risk of Misclassification for Some Community-Acquired Episodes

1. Jauréguiberry S, Paris L, Caumes E. Difficulties in the diagnosis and treatment of acute schistosomiasis. Clin Infect Dis 2009; 48:1163–4 (in this issue). 2. Leshem E, Maor Y, Meltzer E, Assous M, Schwartz E. Acute schistosomiasis outbreak: clinical features and economic impact. Clin Infect Dis 2008; 47:1499–506. 3. Meltzer E, Artom G, Marva E, Assous MV, Rahav G, Schwartzt E. Schistosomiasis among travelers: new aspects of an old disease. Emerg Infect Dis 2006; 12:1696–700. 4. Bottieau E, Clerinx J, de Vega MR, et al. Imported Katayama fever: clinical and biological features at presentation and during treatment. J Infect 2006; 52:339–45. 5. Raccurt CP, El Samad Y, Chouaki T, et al. Bilharziasis caused by Schistosoma mansoni in a traveler returning from Guinea: failure of serodiagnostic testing [in French]. Med Trop (Mars) 2007; 67:175–8. 6. Pitkanen YT, Peltonen M, Lahdevirta J, Meri S, Evengard B, Linder E. Acute schistosomiasis mansoni in Finnish hunters visiting Africa: need for appropriate diagnostic serology. Scand J Infect Dis 1990; 22:597–600. 7. Alonso D, Munoz J, Gascon J, Valls ME, Corachan M. Failure of standard treatment with praziquantel in two returned travelers with Schistosoma haematobium infection. Am J Trop Med Hyg 2006; 74:342–4. 8. Grandiere-Perez L, Ansart S, Paris L, et al. Efficacy of praziquantel during the incubation and invasive phase of Schistosoma haematobium schistosomiasis in 18 travelers. Am J Trop Med Hyg 2006; 74:814–8.