Juan J. Camarena

Prognostic factors of mortality in patients with community-acquired bloodstream infection with severe sepsis and septic shock ☆,☆☆

PURPOSE The purpose of the study was to determine the independent risk factors on mortality in patients with community-acquired severe sepsis and septic shock. METHODS A single-site prospective cohort study was carried out in a medical-surgical intensive care unit in an academic tertiary care center. One hundred twelve patients with community-acquired bloodstream infection with severe sepsis and septic shock were identified. Clinical, microbiologic, and laboratory parameters were compared between hospital survivors and hospital deaths. RESULTS One-hundred twelve patients were included. The global mortality rate was 41.9%, 44.5% in septic shock and 34.4% in severe sepsis. One or more comorbidities were present in 66% of patients. The most commonly identified bloodstream pathogens were Escherichia coli (25%) and Staphylococcus aureus (21.4%). The proportion of patients receiving inadequate antimicrobial treatment was 8.9%. By univariate analysis, age, Acute Physiology and Chronic Health Evaluation II score, at least 3 organ dysfunctions, and albumin, but neither microbiologic characteristics nor site of infection, differed significantly between survivors and nonsurvivors. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.13; 95% confidence interval, 1.06-1.21) and albumin (odds ratio, 0.34; 95% confidence interval, 0.15-0.76) were independent risk factors associated with global mortality in logistic regression analysis. CONCLUSION In addition to the severity of illness, hypoalbuminemia was identified as the most important prognostic factor in community-acquired bloodstream infection with severe sepsis and septic shock.

Epidemiological Cutoff Values for Fluconazole, Itraconazole, Posaconazole, and Voriconazole for Six Candida Species as Determined by the Colorimetric Sensititre YeastOne Method

ABSTRACT In the absence of clinical breakpoints (CBP), epidemiological cutoff values (ECVs) are useful to separate wild-type (WT) isolates (without mechanisms of resistance) from non-WT isolates (those that can harbor some resistance mechanisms), which is the goal of susceptibility tests. Sensititre YeastOne (SYO) is a widely used method to determine susceptibility of Candida spp. to antifungal agents. The CLSI CBP have been established, but not for the SYO method. The ECVs for four azoles, obtained using MIC distributions determined by the SYO method, were calculated via five methods (three statistical methods and based on the MIC50 and modal MIC). Respectively, the median ECVs (in mg/liter) of the five methods for fluconazole, itraconazole, posaconazole, and voriconazole (in parentheses: the percentage of isolates inhibited by MICs equal to or less than the ECVs; the number of isolates tested) were as follows: 2 (94.4%; 944), 0.5 (96.7%; 942), 0.25 (97.6%; 673), and 0.06 (96.7%; 849) for Candida albicans; 4 (86.1%; 642), 0.5 (99.4%; 642), 0.12 (93.9%; 392), and 0.06 (86.9%; 559) for C. parapsilosis; 8 (94.9%; 175), 1 (93.7%; 175), 2 (93.6%; 125), and 0.25 (90.4%; 167) for C. tropicalis; 128 (98.6%; 212), 4 (95.8%; 212), 4 (96.0%; 173), and 2 (98.5; 205) for C. glabrata; 256 (100%; 53), 1 (98.1%; 53), 1 (100%; 33), and 1 (97.9%; 48) for C. krusei; 4 (89.2%; 93), 0.5 (100%; 93), 0.25 (100%; 33), and 0.06 (87.7%; 73) for C. orthopsilosis. All methods included ≥94% of isolates and yielded similar ECVs (within 1 dilution). These ECVs would be suitable for monitoring emergence of isolates with reduced susceptibility by using the SYO method.

Impact of nosocomial polymicrobial bloodstream infections on the outcome in critically ill patients

The aims of this study were to compare the clinical and microbiological characteristics from patients with polymicrobial bloodstream infections (BSI) to those from patients with monomicrobial BSI and to determine their influence on the prognosis. A prospective study was conducted on 371 nosocomial BSI in an intensive care unit (ICU). Seventy-five (20.2%) of them were polymicrobial. The mean APACHE II score at the onset of bacteremia in polymicrobial and monomicrobial BSI were 17.7 ± 6.6 and 18.9 ± 7.5, respectively (p = 0.228). Severe sepsis and septic shock were present in 68.0% and 50.6% of polymicrobial BSI and in 73.9% and 55.1% of monomicrobial BSI, respectively (p = 0.298 and p = 0.494, respectively). The length of stay and the length of stay post-infection were significantly longer in patients with polymicrobial BSI. APACHE II score at the onset of BSI, high-risk microorganisms, and septic shock were predictors of related mortality, but polymicrobial BSI and inadequate empirical antimicrobial treatment were not. Our findings suggest that the clinical and microbiological characteristics of polymicrobial BSI are not different from monomicrobial BSI, and polymicrobial BSI do not have any influence on the related mortality. However, they occurred in patients with a longer length of stay in the hospital and were associated with longer stays in the hospital after the episode of BSI.

DNA amplification fingerprinting for subtyping Neisseria gonorrhoeae strains

Background and Objectives DNA amplification fingerprinting is used in most epidemiologic studies as a substitute for conventional typing methods. DNA amplification fingerprinting and conventional typing methods were compared in this epidemiologic study of Neisseria gonorrhoeae. Goal of This Study To differentiate 70 Neisseria gonorrhoeae isolates from untreated patients with urogenital gonococcal infection. Study Design Gonococcal strains were characterized by auxo-typing, serotyping, plasmid profile, antibiotic sensitivity, and DNA amplification fingerprinting. The method of unweighted pair-group average linkage was used for cluster analysis. Discriminatory power was calculated applying Simpsons index. Results Amplification of Neisseria gonorrhoeae DNA with primers OPA-03 and OPA-13 produced well-resolved patterns of 15 and 22 DNA fragments, respectively, with a discriminatory power (0.978 with OPA-13 and 0.967 with OPA-03) comparable to that obtained with auxotyping/serotyping combination (D:0.968) or with auxotype/serotype/plasmid profile combination (D:0.983). Correlation between DNA amplification fingerprinting pattern and auxotype/serotype class was not always uniform. Some strains with the same auxotype/serotype/plasmid profile were subdivided by DNA amplification fingerprinting, and vice versa. Conclusion Although auxotype/serotype class and DNA amplification fingerprinting can be used in the epidemiologic characterization of strains, DNA amplification fingerprinting offers a better discriminatory index than the separate serotyping. It is especially useful for differentiating serologically identical strains and nontypable strains. A combination of serotyping and DNA amplification fingerprinting seems to be the best way to differentiate Neisseria gonorrhoeae strains in epidemiologic studies, bringing together the most simple techniques and the best discriminatory power among isolates.

A survey on practices for active surveillance of carriage of multidrug-resistant bacteria in hospitals in the Autonomous Community of Valencia, Spain

A questionnaire-based cross-sectional study was conducted to gather information on current microbiological practices for active surveillance of carriage of multidrug-resistant (MDR) bacteria in hospitals from 14 health departments of the Autonomous Community of Valencia (ACV), Spain, which together provided medical attention to 3,271,077 inhabitants in 2017, approximately 70% of the population of the ACV. The survey consisted of 35 questions on MDR bacteria screening policies, surveillance approach chosen (universal vs. targeted), and microbiological methods and processes in use for routine detection and reporting of colonization by MDR bacteria, including the anatomical sites scheduled to be sampled for each MDR bacterial species, and the methodology employed (culture-based, molecular-based, or both). Our study revealed striking differences across centers, likely attributable to the lack of consensus on optimal protocols for sampling, body sites for screening, and microbiological testing, thus underscoring the need for consensus guidelines on these issues.

Update on the management of intra-abdominal Candida infections

Invasive candidiasis management has improved in the last decade mainly due to the implementation of a great number of clinical guidelines regarding epidemiology, diagnosis and management of different risk profile patients. Nevertheless, controversial issues still remain, especially concerning intra-abdominal fungal infections in critically ill patients. Accordingly, Pemán et al.18 publishes in this number of Revista Iberoamericana de Micologia the article Jávea consensus guidelines for the treatment of Candida peritonitis and other intra-abdominal fungal infections in non-neutropenic critically ill adult patients. The authors, using a DELPHI methodology in an Spanish region, achieved a total of 36 validated recommendations regarding several aspects of intra-abdominal candidiasis (IAC). The employed methodology is perfectly detailed. From October 2014 until October 2016 authors performed three experts meetings. They aimed to achieve a consensus on the management of peritoneal candidiasis based on the Epico strategy13 and concluded that these guidelines might help to optimize the management of Candida intra-abdominal infections in non-neutropenic ICU patients. It is interesting to emphasize and put into context some questions about the areas of information presented in these guidelines and, specifically, to highlight some collateral issues that could allow us to gain a better understanding of IAC: (i) epidemiological aspects of temporal and geographic changes in Candida spp. distribution; (ii) possible applications of the Candida Fluco-R score; (iii) importance of source control as a determining factor in a favorable outcome of IAC, including emergent echinocandin resistance mediated by point mutation within hot spots of FKS genes; (iv) potential extrapolation of candidemia care bundle that could be extrapolated to IAC; and (v) role of antifungal stewardship programs. From an epidemiological point of view, Pemán et al. have made five recommendations regarding IAC. Candida infection epidemiology has changed over recent years, influenced by patient predisposing conditions, local hospital-related factors, and antifungal therapy administered.5 According to Pemán et al. results, Candida

Síndrome febril tras traumatismo abdominal cerrado

bados en anaerobiosis, de Bacteroides spp. En una serie de tres hemocultivos tomados en el momento del ingreso se aislaron dos tipos de bacilos gramnegativos anaerobios estrictos, que se identificaron como Bacteroides grupo no fragilis y Fusobacterium necrophorum, ambos resistentes a penicilina. El paciente fue tratado con metronidazol, gentamicina y cefotaxima por via endovenosa durante 5 semanas y posteriormente con metronidazol y ciprofloxacino hasta completar 3 meses de tratamiento, quedando asintomatico y obteniendose la normalizacion de las pruebas hepaticas y de la funcion renal, asi como la resolucion de las imagenes de la TAC al cabo de un ano. Se realizo estudio baritado de intestino delgado y enema opaco, no encontrandose el origen del foco septico.