María José Ramos

Th1 and Th17 hypercytokinemia as early host response signature in severe pandemic influenza.

IntroductionHuman host immune response following infection with the new variant of A/H1N1 pandemic influenza virus (nvH1N1) is poorly understood. We utilize here systemic cytokine and antibody levels in evaluating differences in early immune response in both mild and severe patients infected with nvH1N1.MethodsWe profiled 29 cytokines and chemokines and evaluated the haemagglutination inhibition activity as quantitative and qualitative measurements of host immune responses in serum obtained during the first five days after symptoms onset, in two cohorts of nvH1N1 infected patients. Severe patients required hospitalization (n = 20), due to respiratory insufficiency (10 of them were admitted to the intensive care unit), while mild patients had exclusively flu-like symptoms (n = 15). A group of healthy donors was included as control (n = 15). Differences in levels of mediators between groups were assessed by using the non parametric U-Mann Whitney test. Association between variables was determined by calculating the Spearman correlation coefficient. Viral load was performed in serum by using real-time PCR targeting the neuraminidase gene.ResultsIncreased levels of innate-immunity mediators (IP-10, MCP-1, MIP-1β), and the absence of anti-nvH1N1 antibodies, characterized the early response to nvH1N1 infection in both hospitalized and mild patients. High systemic levels of type-II interferon (IFN-γ) and also of a group of mediators involved in the development of T-helper 17 (IL-8, IL-9, IL-17, IL-6) and T-helper 1 (TNF-α, IL-15, IL-12p70) responses were exclusively found in hospitalized patients. IL-15, IL-12p70, IL-6 constituted a hallmark of critical illness in our study. A significant inverse association was found between IL-6, IL-8 and PaO2 in critical patients.ConclusionsWhile infection with the nvH1N1 induces a typical innate response in both mild and severe patients, severe disease with respiratory involvement is characterized by early secretion of Th17 and Th1 cytokines usually associated with cell mediated immunity but also commonly linked to the pathogenesis of autoimmune/inflammatory diseases. The exact role of Th1 and Th17 mediators in the evolution of nvH1N1 mild and severe disease merits further investigation as to the detrimental or beneficial role these cytokines play in severe illness.

Clinical Significance of Donor-Unrecognized Bacteremia in the Outcome of Solid-Organ Transplant Recipients

We evaluated the clinical significance of unrecognized bacteremia in the organ donor (i.e., blood culture results that were reported to be positive after transplantation) on the outcome of transplant recipients. Twenty-nine of 569 liver and heart donors (5%) had bacteremia at the time of organ procurement, but there were no documented instances of transmission of the isolated bacteria from the donor to the recipient. Unrecognized bacteremia in the donor does not have a negative clinical impact on the outcome of organ transplant recipients.

The Use of Rifampicin-Miconazole—Impregnated Catheters Reduces the Incidence of Femoral and Jugular Catheter-Related Bacteremia

BACKGROUND The guidelines of the Centers for Disease Control and Prevention do not recommend the use of an antimicrobial- or antiseptic-impregnated catheter for short-term use. In previous studies, we have found a higher incidence of central venous catheter-related bacteremia among patients with femoral and central jugular accesses than among patients with other venous accesses. OBJECTIVE The objective of our study was to determine the incidence of central venous catheter-related bacteremia associated with rifampicin-miconazole-impregnated catheters and standard catheters in patients with femoral and central jugular venous accesses. METHODS This was a cohort study, conducted in the 24-bed polyvalent medical-surgical intensive care unit of a university hospital. We included patients who were admitted to the intensive care unit from 1 June 2006 through 30 September 2007 and who underwent femoral or central jugular venous catheterization. RESULTS We inserted 184 femoral (73 rifampicin-miconazole-impregnated catheters and 111 standard catheters) and 241 central jugular venous catheters (114 rifampicin-miconazole-impregnated catheters and 127 standard catheters). We found a lower rate of central venous catheter-related bacteremia associated with rifampicin-miconazole-impregnated catheters than with standard catheters among patients with femoral access (0 vs. 8.62 cases per 1000 catheter-days; odds ratio, 0.13; 95% confidence interval, 0.00-0.86; P = .03) and among patients with central internal jugular access (0 vs. 4.93 cases per 1000 catheter-days; odds ratio, 0.13; 95% confidence interval, 0.00-0.93; P = .04). CONCLUSIONS Rifampicin-minonazole-impregnated catheters are associated with a statistically significant reduction in the incidence of catheter-related bacteremia in patients with short-term catheter use at the central jugular and femoral sites.

Ventilator-associated pneumonia with or without toothbrushing: a randomized controlled trial

Certain guidelines for the prevention of ventilator-associated pneumonia (VAP) recommend oral care with chlorhexidine, but none refer to the use of a toothbrush for oral hygiene. The role of toothbrush use has received scant attention. Thus, the objective of this study was to compare the incidence of VAP in critical care patients receiving oral care with and without manual brushing of the teeth. This was a randomized clinical trial developed in a 24-bed medical-surgical intensive care unit (ICU). Patients undergoing invasive mechanical ventilation for than 24 h were included. Patients were randomly assigned to receive oral care with or without toothbrushing. All patients received oral care with 0.12 % chlorhexidine digluconate. Tracheal aspirate samples were obtained during endotracheal intubation, then twice a week, and, finally, on extubation. There were no significant differences between the two groups of patients in the baseline characteristics. We found no statistically significant differences between the groups regarding the incidence of VAP (21 of 217 [9.7 %] with toothbrushing vs. 24 of 219 [11.0 %] without toothbrushing; odds ratio [OR] = 0.87, 95 % confidence interval [CI] = 0.469–1.615; p = 0.75). Adding manual toothbrushing to chlorhexidine oral care does not help to prevent VAP in critical care patients on mechanical ventilation.

Periodically changing ventilator circuits is not necessary to prevent ventilator-associated pneumonia when a heat and moisture exchanger is used

OBJECTIVE To analyze the efficacy of periodically changing ventilator circuits for decreasing the rate of ventilator-associated pneumonia when a heat and moisture exchanger (HME) is used for humidification. The Centers for Disease Control and Prevention recommended not changing the circuits periodically. DESIGN Randomized, controlled trial conducted between April 2001 and August 2002. SETTING A 24-bed, medical-surgical intensive care unit in a 650-bed, tertiary-care hospital. PATIENTS All patients requiring mechanical ventilation during more than 72 hours from April 2001 to August 2002. INTERVENTIONS Patients were randomized into two groups: (1) ventilation with change of ventilator circuits every 48 hours and (2) ventilation with no change of circuits. Throat swabs were taken on admission and twice weekly until discharge to classify pneumonia as endogenous or exogenous. RESULTS Three hundred four patients (143 from group 1 and 161 from group 2) with similar characteristics (age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic group, and mortality) were analyzed. There was no significant difference in the rate of pneumonia between the groups (23.1% vs 23.0% and 15.5 vs 14.8 per 1,000 ventilator-days). There was no significant difference in the incidence of exogenous pneumonia per 1,000 days of mechanical ventilation (1.71 vs 1.25). There was no difference in the distribution of microorganisms causing pneumonia. CONCLUSIONS Circuit change using an HME for humidification does not decrease pneumonia and represents an unnecessary cost.

Lower associated costs using rifampicin-miconazole‒impregnated catheters compared with standard catheters.

Previous cost-effectiveness analyses found that antibiotic-impregnated catheters decrease the incidence of catheter-related bloodstream infection (CRBSI) as well as the costs related to central venous catheter (CVC) use, including increased hospital length of stay. The effect varied greatly among the studies, however. In this retrospective cohort study, compared with standard catheters, the use of rifampicin-miconazole-impregnated catheters was associated with lower CRBSI incidence and immediate CVC-related costs (taking into account only the costs of CVC, diagnosis, and treatment of CRBSI) (P < .001). Our data indicate that the use of rifampicin-miconazole-impregnated catheters can save associated costs.

Rifampicin–miconazole-impregnated catheters save cost in jugular venous sites with tracheostomy

Antimicrobial-impregnated catheters are more expensive than standard catheters (S-C). A higher incidence of catheter-related bloodstream infection (CRBSI) has been found in jugular venous access with tracheostomy than without tracheostomy. The objective of this study was to determine central venous catheter (CVC)-related costs (considering only the cost of the CVC, diagnosis of CRBSI, and antimicrobial agents used to treat CRBSI) using rifampicin–miconazole-impregnated catheters (RM-C) or S-C in jugular venous access with tracheostomy. We performed a retrospective cohort study of patients admitted to the intensive care unit (ICU) with tracheostomy who received one or more jugular venous catheters. RM-C showed a lower incidence of CRBSI compared with S-C (0 vs. 20.16 CRBSI episodes/1,000 catheter-days; odds ratio = 0.05; 95% confidence interval = 0.001–0.32; p < 0.001) and lower CVC-related costs (including the cost of the CVC, diagnosis, and treatment of CRBSI) (€11.46 ± 6.25 vs. €38.11 ± 77.25; p < 0.001) in jugular venous access with tracheostomy. The use of RM-C could reduce CVC-related costs in jugular venous access with tracheostomy. The results of our study may contribute to clinical decision-making and selection of those patients who could benefit from the use of antimicrobial-impregnated catheters.

Estudio del primer brote por Enterococcus faecium vanA en Canarias

INTRODUCTION In July, 2005 the first vancomycin-resistant Enterococcus faecium (VREF) with a genotype vanA was isolated in Hospital Universitario de Canarias (HUC). From September to December 2005, VREF vanA was isolated from another 15 patients (3 nosocomial infections and 12 rectal carriers). All of them were kidney transplant patients hospitalized in the Nephrology ward. This study describes the first VREF vanA outbreak in the HUC and the epidemiological link of the first VREF vanA isolates found in another two university hospitals in the Canary Islands. MATERIALS AND METHODS We studied a total of 22 VREF isolates by microbiological and molecular methods. Epidemiological and clinical data of the patients involved were collected. RESULTS AND CONCLUSIONS We confirmed that these VREF isolates belonged to the same clone using pulse-field gel electrophoresis (PFGE). In November 2005 and February 2006, the first VREF were isolated in two other University Hospitals in the Canary Islands and we also confirmed the link with the HUC cluster by comparison of patient-related information with the molecular typing data. These VREF isolates belonged to the ST18 associated to the Clonal Complex-17 (CC17). CC17 is the major hospital adapted lineage, representing a polyclonal population and associated to VREF outbreaks and infections in the five continents.

Prediction of surgical site infection after colorectal surgery

BACKGROUND Surgical site infection (SSI) after colorectal surgery is a frequent complication associated with substantial morbidity. Our objective was to identify surgical predictors of SSI in patients undergoing colorectal surgery using a retrospective case-control design. MATERIAL AND METHODS Randomly selected patients from all those undergoing colorectal surgery (2007-2013). Cases were patients who developed SSI within 30 days. Controls were patients who did not develop SSI within 30 days. Patients undergoing multiple procedures during a single surgical intervention were excluded. SSI was diagnosed according to Centers for Disease Control and Prevention definitions. The main outcome measures were SSI, surgical variables, and cumulative survival (Kaplan-Meier method). Variables considered predictors were compared using log-rank test. RESULTS Of 911 patients undergoing colorectal surgery, 221 developed SSI (24.3%; 95% confidence interval, 24.0-24.6). On univariate analysis, significant risk factors for SSI were: female sex (P = .02), >72 hours preoperative stay (P = .04), open surgery (P = .08), incision class: contaminated and dirty (P = .001), and emergency procedures (P = .006). On multivariate analysis, significant independent predictors of SSI and survival were dirty surgery (hazard ratio [HR], 2.12; P = .015), contaminated surgery (HR, 1.74; P = .009), female sex (HR, 1.58; P = .003), open surgery, (HR, 1.51; P = .015) and >72 hours preoperative stay (HR, 1.48; P = .024). CONCLUSIONS Dirty or contaminated surgery, female sex, open surgery, and >72 hours preoperative stay were significant predictors of SSI.

Risk factors associated with carbapenemase-producing Klebsiella pneumoniae fecal carriage: A case-control study in a Spanish tertiary care hospital.

HighlightsCase‐control study to identify risk factors for carbapenemase‐producing Klebsiella pneumoniae fecal carriage.This study included 87 cases, 200 controls. Multivariate analysis identified length of stay previous hospitalization, antibiotic use and corticosteroid use as independent risk factors for CPKP rectal carriage.Adherence to infection control practices and directed surveillance programs appear to be critical components for CPKP control programs. &NA; Asymptomatic colonization of the gastrointestinal tract by carbapenemase‐producing Enterobacteriaceae is an important reservoir for transmission that may precede infection. This prospective, observational, case–control study was designed to identify risk factors for carbapenemase‐producing Klebsiella pneumoniae (CPKP) fecal carriage. This study included 87 cases and 200 controls. Multivariate analysis identified length of stay (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.01‐1.03; P = .03), previous hospitalization (OR, 5.89; 95% CI, 1.73‐20.68; P = .01), antibiotic use (OR, 0.20; 95% CI, 0.65‐0.62; P = .01), and corticosteroid use (OR, 0.33; 95% CI, 0.15‐0.74; P = .007) as independent risk factors for CPKP rectal carriage. Length of hospital stay, previous hospitalization, corticosteroid use, and antimicrobial exposure are important risk factors for CPKP rectal colonization. Adherence to infection control practices and directed surveillance programs appear to be critical components for CPKP control programs.