Verónica Pérez-Blanco

Infections caused by OXA-48-producing Klebsiella pneumoniae in a tertiary hospital in Spain in the setting of a prolonged, hospital-wide outbreak

OBJECTIVES We describe clinical and microbiological features of infections caused by OXA-48-producing Klebsiella pneumoniae (O48KP) in the setting of a prolonged, hospital-wide outbreak detected in January 2011. METHODS Clinical, demographic and microbiological data of patients with growth of O48KP in clinical specimens were collected until December 2011. PCR was used to detect carbapenemase and β-lactamase genes. The genetic relationships were determined by automated repetitive-sequence-based PCR. RESULTS Seventy-one patients with clinically guided cultures showing growth of O48KP were identified. Nine were considered to be colonizing rather than causing infection. The most frequent source of infection was the urinary tract (22/62), followed by surgical site infections (17/62). Blood cultures were positive in 23/62 patients. Many patients had significant comorbidity and prolonged hospital stays. In-hospital mortality among patients with O48KP infections was 43.5%. The MIC(90)s of ertapenem, imipenem and meropenem were >32, 16 and 16 mg/L, respectively. No single antimicrobial was active against all the isolates. The antibiotics most active against O48KP were amikacin (97.2% susceptible), colistin (90.1%), tigecycline (73%) and fosfomycin (66.2%). Although eight clones were identified, a predominant clone caused 73.2% of the infections. Multilocus sequence typing (MLST) of the predominant clone gave sequence type (ST) 405 and bla(TEM-1), bla(SHV-76), bla(CTX-M-15) and bla(OXA-1) genes and the insertion sequence IS1999 of the Tn1999 transposon were associated with bla(OXA-48) in this clone. CONCLUSIONS To our knowledge, this is the largest reported series of infections caused by O48KP in the setting of a single-centre outbreak and provides further input on the clinical relevance of infections caused by O48KP and the difficulties associated with its detection and control.

Interhospital spread of NDM-7-producing Klebsiella pneumoniae belonging to ST437 in Spain

This study describes an interhospital spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) producing NDM-7 carbapenemase that started in December 2013 in Madrid, Spain. NDM-7-producing CRKP were isolated from urine, rectal swabs or blood samples from seven patients admitted to three different hospitals (Hospital Universitario La Paz, Hospital de Cantoblanco and Hospital Central de la Cruz Roja). The isolates were resistant to all antimicrobials tested except colistin and fosfomycin. One blood isolate was susceptible to minocycline and tigecycline but was resistant to fosfomycin. All isolates were closely related by pulsed-field gel electrophoresis (PFGE) and DiversiLab(®) analysis and belonged to multilocus sequence typing (MLST) sequence type 437. In addition, blaNDM-7, blaTEM-1, blaCTX-M-15 and aac(3)-IIa were identified. Family contacts of the index case were negative for NDM-producing bacteria. The outbreak occurred in two separate waves and the cases associated with Hospital de Cantoblanco had been admitted to the same room. Environmental samples from the trap of a sink and a shower in this room were positive for NDM-7-producing CRKP. To our knowledge, this is the first reported worldwide outbreak of NDM-7-producing CRKP. No relationship with the Indian continent, the Balkans or the Middle East could be established. Frequent transfer of aged or chronically ill patients between the facilities involved may have favoured the spread of NDM-7-producing CRKP. The spread of the second wave in Hospital de Cantoblanco probably occurred as a result of transmission from an environmental reservoir.

Evaluación de un paquete de medidas para la prevención de la infección de localización quirúrgica en cirugía colorrectal

OBJECTIVE To assess the effectiveness of a protocol for prevention of surgical site infection (SSI) in colorectal surgery. PATIENTS AND METHODS Evaluation of 2 cohorts of patients undergoing colon and rectal surgery in a tertiary public hospital: A historical cohort (2008-2011) and a prospective one (after the implementation of the program in 2012). The main measures established were: Adequacy of preoperative antimicrobial prophylaxis, maintaining patient normothermia and appropriate glove change during the intervention. Comparability of the two cohorts was determined by a bivariate analysis of age, sex, NNIS index, ASA index, surgical time, perioperative transfusion, diagnosis, diabetes and renal failure. RESULTS We assessed 342 patients (256 underwent colon surgery and 86 rectal surgery), divided into 2 cohorts: prior period (218), and post-implementation period (124). The cumulative incidence of SSI in the first cohort was 27.5% (95% CI, 21.6- 33.4), and in the post-intervention cohort 16.9% (95% CI, 10.3-23.5, P=.03). Postoperative mortality was 9.2% (95% CI, 5.4-13) in the first cohort and 3.2% (95% CI, 0.1-6.3) in the post-intervention cohort (P=.04). The inadequacy of prophylaxis decreased from 37.4% (95% CI, 30.4-44.6) to 18.9% (95% CI, 11.9- 26.1) (P=.001). CONCLUSION A significant decrease in the frequency of SSI, post-surgical mortality and inadequate antimicrobial prophylaxis is verified after the implementation of a protocol in colorectal surgery.

Satisfacción del paciente urológico en consultas externas

Resumen Objetivo Valorar la satisfaccion de los pacientes de consultas externas del servicio de urologia del Hospital La Paz e identificar posibles problemas en la atencion. Material y metodo Estudio transversal utilizando un cuestionario de satisfaccion que se entrego a los pacientes que acudieron a los centros de consultas externas de urologia durante una semana del mes de noviembre de 2002. Resultados La encuesta fue contestada por un total de 532 pacientes. La mitad de los pacientes pertenecen al grupo de mayores de 65 anos. El 72,2% conoce el nombre del urologo que les atiende, mientras que solo el 27,4% conoce el de la/el enfermera/o. Al estratificar esta variable por centro, observamos que el numero de pacientes que afirma conocer el nombre de su urologo en consultas hospitalarias es superior (197; 86,4%) que en centros de especialidades (171; 70%). En los centros de especialidades, el 22,9% afirma que el tiempo dedicado a su consulta fue “escaso” o “muy escaso”; en las cuatro salas del hospital es del 6,7%. Encontramos diferencias significativas al comparar la satisfaccion entre centros respecto a las variables informacion sobre riesgos del diagnostico y tratamiento, instrucciones dadas tras el alta y descripcion de los sintomas por los que el paciente debe consultar de nuevo al urologo. La satisfaccion es mayor en consultas hospitalarias. Ciento setenta y dos (32,3%) de los pacientes han realizado sugerencias. El grupo mas numeroso corresponde a las relacionadas con la mejora del sistema de citaciones, la reduccion de la lista de espera y el excesivo tiempo de espera previo a la consulta. La satisfaccion global con el servicio presenta diferencias significativas entre pacientes que acuden a consultas hospitalarias y a centros de especialidades externos. Conclusiones El conocimiento del nombre de los profesionales sanitarios, el tiempo dedicado a consulta y la informacion sobre riesgos derivados del diagnostico y tratamiento son aspectos muy valorados por los pacientes de consultas de urologia y estan asociados a una mayor satisfaccion global con el servicio. La espera previa a la consulta y las dificultades para la citacion son las oportunidades de mejora expresadas mayoritariamente en el apartado de sugerencias. Existen diferencias en la satisfaccion entre pacientes de consultas hospitalarias y consultas de centros de especialidades.

Diseño y validación de una vía clínica para la apendicitis aguda infantil

Resumen Objetivo Elaboracion, implantacion y evaluacion de una via clinica (VC) para la apendicitis aguda en el Hospital Infantil La Paz de Madrid. Material y metodo Coordinacion del equipo de trabajo por la unidad de calidad del hospital. Revision bibliografica buscando la mejor evidencia cientifica. Diseno de los documentos de la VC. Implantacion de la via en junio de 2003. Realizacion del estudio piloto descriptivo. Resultados Diseno de los documentos de la VC mediante el consenso de todos los profesionales implicados en el proceso. Para ello se realizaron 5 reuniones durante los meses de abril y mayo de 2003. Los documentos son los siguientes: matriz temporal, hoja de informacion para el paciente durante su estancia hospitalaria, recomendaciones al alta, hoja de registro para tratamientos y cuidados de enfermeria, hoja de variaciones, encuesta de satisfaccion, indicadores para la evaluacion. Realizacion del estudio piloto descriptivo previo a la implantacion definitiva: la estancia media se ajusta a la estipulada en la VC (6,8 dias en apendicitis complicadas y 3,0 en no complicadas), las variaciones se produjeron por causa del paciente (13,5%) y por los profesionales (29,7%), ninguna por la institucion. El tipo de antibioterapia fue el estipulado en la mayoria de los casos (94,6%). Conclusiones La implantacion de la via clinica ha facilitado el consenso entre los profesionales. La estandarizacion del tratamiento antimicrobiano ha facilitado el control de la variabilidad clinica no justificada. El cumplimiento de las estancias establecidas se produjo en la mayoria de los pacientes.

Reacciones adversas a medicamentos en el Hospital La Paz registradas en el conjunto mínimo básico de datos (CMBD) durante 2003

Resumen Objetivo Las reacciones adversas medicamentosas (RAM) son un problema de salud publica, cuya magnitud es dificil de cuantificar debido a su infranotificacion. Nuestro objetivo fue identificar y describir las RAM registradas en el conjunto minimo basico de datos (CMBD) del Hospital La Paz durante 2003. Pacientes y metodos Estudio transversal. Se seleccionaron los episodios codificados, segun la CIE-9-MC, como tales en los informes de alta de todos los pacientes hospitalizados durante 2003. Se describieron y analizaron las variables sociodemograficas, las categorias diagnosticas y los tipos de farmacos, entre otras. Resultados De las 50.929 altas registradas en el CMBD, se detectaron 1.092 episodios con al menos una RAM (2,1%). De estos, 217 (0,4% del total) tuvieron como causa principal del ingreso una RAM. Los servicios con mayor numero de pacientes ingresados por esta causa fueron los de oncologia medica y medicina interna. Hallamos diferencias significativas (p Conclusiones El CMBD es una herramienta util para la identificacion, la cuantificacion y el analisis de las RAM.

Desarrollo e implantación de una vía clínica para la cirugía bariátrica

Resumen Objetivo Elaboracion e implantacion de una via clinica para la cirugia de la obesidad en el Hospital Universitario La Paz. Material y metodos Coordinacion por parte de la unidad de calidad del equipo de trabajo; revision bibliografica en busca de la mejor evidencia cientifica publicada; diseno de los documentos de la via clinica mediante el consenso entre todos los profesionales implicados en el proceso. La implantacion de la via clinica se realizo en mayo de 2003. Resultados Se obtienen los siguientes resultados: algoritmo de actuacion en el paciente obeso; secuencia de evaluaciones prequirurgicas; hoja de informacion preoperatoria para el paciente; matriz temporal para los profesionales con evaluaciones, determinaciones, tratamiento y cuidados de enfermeria, actividad, dieta, objetivos y criterios; hoja de informacion iconografica para el paciente durante su estancia hospitalaria; hoja de informacion al paciente sobre el postoperatorio inmediato; hoja de tratamientos y cuidados de enfermeria en planta (preoperatorio), quirofano, reanimacion y planta (postintervencion); hoja de variaciones de la via clinica; encuesta de satisfaccion e indicadores para la evaluacion. Conclusiones La via clinica facilita el consenso de este proceso multidisciplinario, y mejora el trabajo en equipo, los tiempos de espera y la implicacion de los profesionales. Asimismo, mejora la informacion proporcionada a los pacientes y aumenta la implicacion de estos en sus cuidados.

Bla-OXA48 gene microorganisms outbreak, in a tertiary Children's Hospital, Over 3 years (2012-2014): Case Report.

Rationale: Carbapenem-resistant Enterobacteriaceae are an emerging problem in children. Nosocomial spread remains the principal risk factor for acquisition of these microorganisms. Patients concerns: We describe an outbreak of Klebsiella pneumoniae OXA48 (KOXA48) in a tertiary childrens hospital during the years 2012 to 2014, as well as the preventive measures put in place in colonized and infected cases. Diagnoses: We studied, “in vitro,” the KOXA48 susceptibility to antiseptics and surface disinfectants. Moreover, an epidemiological surveillance of infection or colonization by these microorganisms, with molecular typing of the KOXA48, was performed, and carbapenemase genes were confirmed by polymerase chain reaction (PCR). Interventions: The bundles recommended (early detection, cohorting of children and health care workers [HCW], contact precautions, etc.) to control the KOXA48 outbreak were taken from those described in the centers for disease control (CDC) 2012 guide, and adapted according to our experience in controlling other outbreaks. Outcomes: All the KOXA48 microorganisms isolated from children belonged to the same strain (ST11) and were susceptible to alcohol solutions but not the surface disinfectant previously employed in our hospital (tensoactive). We reinforced the surface disinfection using a double application (tensoactive + alcohol). The outbreak of KOXA48 begun in 2012 (16 cases in neonatal intensive care unit [NICU] and 1 in pediatric intensive care unit [PICU]) ended before the end of the same year and was not transmitted to new patients in 2013 to 2014, despite readmission of some colonized cases, in intensive care units (ICUs) and other units, of our children hospital. Lessons: Infected children are the tip of the iceberg (3/17) of KOXA48 prevalence making it necessary to identify the cases colonized by these bacteria. At the beginning of the outbreak, the susceptibility of the epidemic strain to antiseptics and surface disinfectants should be studied. Moreover, the measures taken (cohorts, contact precautions, etc.) must be thorough in both colonized and infected cases, immediately, after microbiological diagnosis.

Population structure of OXA-48-producing Klebsiella pneumoniae ST405 isolates during a hospital outbreak characterised by genomic typing

OBJECTIVES The aim of this study was to investigate the structure of a broad and sustained hospital outbreak of OXA-48-producing Klebsiella pneumoniae (KpO48) belonging to sequence type 405 (ST405). METHODS Whole-genome sequencing and comparison of ten ST405 KpO48 isolates obtained from clinical samples in our hospital was performed. Using stringent criteria, 36 single nucleotide polymorphisms (SNPs) were detected (range 0-21 in pairwise comparisons), and allele-specific PCR was used to call the SNPs among a larger set of isolates. RESULTS Several haplotypes were identified within the population. The haplotypes did not show a spatial structure, but a temporal evolution of sequential haplotype replacements was observed. CONCLUSIONS The dispersed spatial distribution suggests a reservoir formed by a large pool of colonised patients, and the temporal replacement pattern suggests that the sustained outbreak was composed of several small outbreaks that appeared and rapidly dispersed to several units.