Víctor Baños

Predictors of mortality in patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia: the role of empiric antibiotic therapy

The objective of this study was to evaluate prognostic factors and the influence of different empiric antibiotic therapies on outcome and mortality in a cohort of 100 inpatients with bacteraemia (84 cases nosocomial) caused by methicillin-resistant Staphylococcus aureus (MRSA). Patients were investigated by means of a standard protocol at a 944-bed hospital in the years 2000–2004. Empiric antibiotic therapies included vancomycin (n = 49), teicoplanin (n = 20), linezolid (n = 17), other antibiotics active in vitro (n = 7), and inactive antibiotics (n = 7). Overall mortality was 40% (12% among linezolid-treated patients; 46.3% among glycopeptide-treated patients). In bivariate analyses, the following factors were statistically associated with higher mortality: rapidly fatal underlying disease, altered mental status, metabolic acidosis, and acute severe clinical condition at the onset of bacteraemia; development of complications (septic shock, renal failure, and disseminated intravascular coagulopathy); empiric monotherapy with glycopeptides (vs combination therapy with an aminoglycoside); and inadequate empiric treatment. Empiric therapy with linezolid was associated with lower mortality. In multivariate analysis, risk factors associated with higher mortality included acute severity of illness (OR 7.49; 95%CI 1.19–25.3) and altered mental status (OR 4.83; 95%CI 1.22–19.15) at onset, complications (OR 3.42; 95%CI 1.02–17.46), and inappropriate empiric treatment (OR 7.6; 95%CI 1.87–31.14). In multivariate analysis limited to patients who received empiric therapy with either linezolid (n = 17) or glycopeptides (n = 69), linezolid was associated with greater rates of survival (OR 7.7; 95%CI 1.1–53) and microbiological eradication (OR 11.76; 95%CI 1.46–90.9) but not with fewer complications (OR 0.71; 95%CI 0.16–3.25). In conclusion, the main prognostic factors associated with mortality in patients with MRSA bacteraemia are complications, acute severe clinical condition at onset, and inappropriate empiric treatment. Empiric therapy with linezolid was associated with greater survival and more successful microbiological eradication but did not reduce complications.

Six-Year Prospective Study of Risk and Prognostic Factors in Patients with Nosocomial Sepsis Caused by Acinetobacter baumannii

Abstract In this prospective study, the risk factors associated with nosocomial sepsis Caused by Acinetobacter baumannii or Pseudomonas aeruginosa were compared. Prior use of broad-spectrum antibiotics, urinary tract catheter, prior surgery, and mechanical ventilation were significantly associated with nosocomial sepsis caused by Acinetobacter baumannii. The mean prognostic factors significantly associated with mortality were known focus of infection, multiresistant Acinetobacter baumannii, and inappropriate antibiotic treatment. Adequate knowledge of these findings is important to ensure appropriate management of patients and rational use of antibiotics.

Prospective study of epidemiology and prognostic factors in community-acquired pneumonia.

Of 342 patients with community-acquired pneumonia, 100 were diagnosed etiologically. In these patients, disease epidemiology, prognostic factors, and influence of antibiotic treatment were analyzed prospectively. Fifty-two patients were treated with a broad-spectrum antibiotic (ceftriaxone), and 48 received a medium-spectrum antibiotic (cefuroxime); some patients in each group also received erythromycin.Streptococcus pneumoniae was the most frequently isolated microorganism (43%), followed byChlamydia pneumoniae (21%),Haemophilus influenzae (19%), andMycoplasma pneumoniae (11%). Factors significantly associated with increased mortality were initially critical or poor clinical condition, involvement of two or more lobules, and complications. Prior administration of antibiotics was predictive of penicillin and erythromycin resistance inStreptococcus pneumoniae, but had no effect on the course of the disease. Eight patients died, 89 were cured, and three had recurrences; there was no significant difference in outcome between treatment groups, regardless of whether patients also received erythromycin. Increased knowledge of epidemiological, predictive, and prognostic factors can significantly improve early diagnosis of community-acquired pneumonia and facilitate the choice of appropriate antibiotic treatment, thereby helping to reduce morbidity and mortality.

Nosocomial candidemia at a general hospital: The change of epidemiological and clinical characteristics. A comparative study of 2 cohorts (1993–1998 versus 2002–2005)

BACKGROUND Nosocomial candidemia (NC) is associated with high mortality, increased hospital stay and greater economical cost. AIMS To evaluate epidemiological and clinical aspects of 2 different cohorts of non-paediatric patients with NC. METHODS A retrospective observational and comparative study of patients with NC. Patients were identified by review of results of blood cultures from the hospital microbiology laboratory. We analysed epidemiological, clinical, microbiological and laboratory data and changes in the 2 cohorts: 1993-1998 (P1) and from 2002 to 2005 (P2). RESULTS Eighty patients were studied during P1 and 107 during P2; incidence was 9/10,000 in P1 and 15.8/10,000 admitted patients in P2 (p<0.05). Mean age was 52 years in P1 and 61 years in P2 (p<0.05); 66% and 49% NC were due to Candida albicans in P1 and P2, respectively (p<0.05); diabetes was present in 12% in P1 and in 25% in P2 (p<0.05). All of the patients had previously received at least one course of broad-spectrum antibiotics. A statistically significant difference (p<0.05) in predisposing conditions was identified in central intravenous line rate (100% in P1 and 91% in P2) and previous surgery (43% in P1 and 78% in P2). Acute severity of illness at onset and complications were more frequent in P2 (p<0.05). Mortality rate was similar in P1 and P2 (51% and 49.5%, respectively). CONCLUSIONS Frequency of NC has increased and non-albicans Candida is now more frequent than C. albicans. Although acute severity of illness at onset and complications are now more frequent, mortality remains the same.

Clinical significance of anaerobic bacteremias in a general hospital

SummaryA prospective study was designed to investigate anaerobic bacteremias and evaluate their incidence and significance in a general hospital. One or more blood cultures positive for anaerobic microorganisms were analyzed from each of a total of 61 patients hospitalized between January 1988 and April 1992, in accordance with an established protocol. The clinical repercussions of bacteremia were also analyzed. Two percent of blood cultures were positive for anaerobes, with an incidence of 0.6 cases per 1000 hosphitalized patients. The most frequently isolated anaerobes were Bacteroides fragilis and Clostridium perfringens. Intraabdominal disease was the route of entry in 50% of the patients. A death rate of 37.3 % was mostly attributed to B. fragilis. Hospitalization in the surgical department, nosocomial acquisition, previous surgery, critical initial clinical status and the presence of complications were significantly associated with increased death rates. No significant differences were found in the clinical course between patients whose antibiotic treatment was judged adequate and those for whom it was considered inadequate. The frequency and incidence of anaerobic bacteremia was low in our hospital. The well-known clinical and epidemiological characteristics of these infections facilitates their prompt diagnosis and empirical treatment with antibiotics of proven effectiveness against anaerobes.

Infección de prótesis articulares: epidemiología y clínica. Estudio prospectivo 1992-1999

Introduccion La infeccion protesica es una complicacion grave por los problemas diagnosticos que plantea. Objetivos Estudiar las caracteristicas epidemiologicas y clinicas de las infecciones asociadas a protesis articulares para mejorar su diagnostico y manejo. Pacientes y metodos Desde diciembre de 1992 hasta diciembre de 1999, hemos evaluado de forma prospectiva a 110 pacientes con infecciones de protesis articulares. El diagnostico se llevo a cabo siguiendo criterios clinicos, microbiologicos y radiologicos, aceptados para este tipo de estudios. Resultados Su incidencia fue del 5,1%, 110 casos de 1.400 implantes articulares insertados durante el periodo de estudio. La edad media fue de 59,6 anos (intervalo, 18-79 anos), en su mayoria mujeres, 63 (57,2%). Su localizacion mas frecuente fue la rodilla, 42 casos (38%), la cadera, 29 (26%), el hombro, 1 (1%) e implantes oseos, 38 (34%). En 29 pacientes (26,3%) se encontraron enfermedades de base, entre las que destacaba diabetes en 17 casos. Como antecedentes mas importantes figuraba el uso previo de antibioticos en 58 pacientes (51%), a expensas principalmente de ciprofloxacino. Se documentaron microbiologicamente 66 casos (60%), y se aislaron grampositivos, 58,2% y gramnegativos, 32,8%, a expensas fundamental de Staphylococcus sp. y P. aeruginosa respectivamente, encontrandose anaerobios en 9%. De todos los casos, 67 eran infecciones precoces, 25 intermedias y 18 tardias, y todos los casos presentaron dolor y signos inflamatorios. En 46 casos (41,8%) se detecto fistula con supuracion, y solo 5 casos (4,8%) fiebre. Conclusiones La infeccion es una complicacion importante tras el implante de protesis articular; esta causada, fundamentalmente, por cocos grampositivos y presenta clinicamente una mayor afectacion local que sistemica.

Infección de implantes osteoarticulares: factores pronósticos e influencia del tratamiento antibiótico prolongado en su evolución. Estudio prospectivo, 1992-1999

Introduccion Las infecciones de los implantes osteoarticulares (IOA) son de gran importancia por su morbilidad, tendencia a mayores recidivas y elevado coste sanitario Objetivos Estudio de los factores pronosticos y la influencia del tratamiento antibiotico prolongado en su evolucion Metodos Se han estudiado de forma prospectiva 110 pacientes diagnosticados de infecciones de implantes osteoarticulares. En todos los pacientes se realizaron estudios clinicos, analiticos, microbiologicos y gammagraficos con tecnecio, galio y leucocitos marcados, efectuandose controles a los 7, 15, 30 dias del inicio y despues cada 3 meses hasta el final del tratamiento y despues cada 6 meses hasta un ano despues de su suspension. El tratamiento antibiotico inicial se realizo de acuerdo con las caracteristicas epidemiologicas segun el tipo de infeccion, modificandolo en relacion con los microorganismos aislados. La duracion del tratamiento se establecio en funcion del tipo de paciente, protesis, gravedad de la infeccion y curso evolutivo. Su evolucion se ajusto a los criterios de curacion, fallo y recidiva Resultados De los 110 casos, 63 eran mujeres y 37 varones con una edad media de 59,6 anos (limites, 18 y 79 anos). De ellos, 72 correspondian a protesis articulares (42 de rodilla, 29 de cadera y uno de hombro) y 38 a implantes oseos. El 60% de los episodios se documentaron microbiologicamente. El 60,6% estuvieron causados por cocos grampositivos con predominio del genero estafilococo, el 33,3% por bacilos gramnegativos y el 6,1% por anaerobios. Como factores pronosticos asociados a fracasos o recidivas se encontro de forma significativa la cirugia articular previa, una estancia hospitalaria previa superior a 15 dias, la presencia de diabetes, la documentacion microbiologica y el tratamiento antibiotico con cefuroxima mas rifampicina. La duracion media del tratamiento fue de 9,8 meses (limites, 2 y 17 meses). El tratamiento antibiotico fue el siguiente: 61 pacientes recibieron fluorquinolonas o cotrimoxazol mas rifampicina y 29 cefuroxima-axetilo mas rifampicina. Los restantes 20 pacientes recibieron un solo antibiotico. De los 110 casos, 91 (83%) evolucionaron hacia la curacion. Los fracasos o las recidivas se observaron en 19 enfermos (17% del total de IOA y 26,7% en relacion de las protesis articulares) que requirieron la retirada de la protesis. La tolerancia al tratamiento antibiotico prolongado fue buena Conclusion El tratamiento antibiotico prolongado, con una duracion media de 9,8 meses, influye positivamente en la mejor evolucion de los IOA

Nosocomial candidemia at a general hospital: prognostic factors and impact of early empiric treatment on outcome (2002–2005)

OBJECTIVES To evaluate epidemiological and clinical prognosis factors related to mortality and impact of early empiric treatment on patients with nosocomial candidemia (NC). PATIENTS AND METHODS Observational study of a cohort of 107 adult patients with NC admitted at a tertiary hospital (2002-5). RESULTS In bivariate analysis, risk factors significantly associated with mortality rate (49.5%) were: age >65 years, previous steroid treatment, solid organ transplant, acute severity of illness, shock, renal failure and respiratory distress at onset, delayed or inadequate antifungal treatment, non-removal of central venous catheter and associated post-surgical bacterial sepsis or respiratory infection. In multivariate analysis, risk factor associated with mortality was acute severity of illness at onset (OR 76.9; CI 12.5-500) being early and adequate treatment (OR 11.8; CI 1.7-81.2) and early (<48h) removing of central venous catheter (OR 12.2; CI 1.9-74.9) factors associated with cure; there was no statistically significant difference between fungistatic (azoles) or fungicidal (amphotericin or caspofungin) treatment. CONCLUSIONS Acute severity of illness at onset is associated with mortality in patients with NC whereas early and adequate treatment and early removing of central venous catheter are associated with cure.

Estudio comparativo de pacientes con bacteriemia por Staphylococcus aureus sensible a la meticilina frente a S. aureus resistente a la meticilina: epidemiología y factores pronósticos

Fundamento y objetivo: Hay controversia sobre la influencia de la resistencia a la meticilina en el pronostico de los pacientes con bacteriemia por Staphylococcus aureus. En este trabajo, analizamos los patrones clinicos y los factores pronosticos que se relacionan con el desarrollo de complicaciones y la mortalidad en pacientes con bacteriemia por S. aureus y valoramos la influencia de la resistencia a la meticilina (S. aureus sensible a la meticlina [SASM] frente a S. aureus resistente a la meticilina [SARM]). Pacientes y metodo: Estudio prospectivo y comparativo de 213 pacientes con bacteriemia por S. aureus. Resultados: Del total de pacientes con bacteriemia, 131 (61,5%) correspondian a SASM y 82 (38,5%) a SAMR. Se asociaron a SARM la adquisicion nosocomial de la infeccion, la presencia de una enfermedad de base rapidamente fatal y ciertos factores predisponentes (diabetes mellitus, utilizacion de cateteres vasculares, estancia previa en unidades de cuidados intensivos y uso previo de antibioticos). Los pacientes con bacteriemia por SARM presentaron mayor gravedad clinica y desarrollaron complicaciones con mas frecuencia que los pacientes con bacteriemia por SASM. La mortalidad de los casos con bacteriemia por SARM fue del 42,6%, mientras que en la de SASM fue del 16% (p < 0,05). En el analisis multivariado, del total de casos de bacteriemia por S. aureus, las variables que se asociaron a un fracaso terapeutico mayor fueron la gravedad de la enfermedad de base, una situacion clinica inicial critica-mala y el tratamiento empirico no adecuado; la resistencia a la meticilina no se asocio a mas mortalidad. Conclusiones: En los pacientes con bacteriemia por S. aureus, la resistencia a la meticilina no se asocia a una mayor mortalidad cuando se hace un analisis ajustado por otros factores clinicos/pronosticos. La gravedad de la enfermedad de base, la situacion clinica inicial critica-mala y el tratamiento empirico no adecuado son los factores pronosticos relacionados con el fracaso terapeutico en los pacientes con bacteriemia por S. aureus

Effectiveness of Immunomodulating Treatment (Thymostimulin) in Chronic Obstructive Pulmonary Disease

We conducted a prospective randomized study to assess the effect of thymostimulin in patients with long-standing chronic obstructive pulmonary disease (COPD) during a 1-year follow-up. A total of 38 patients in the intervention group and 40 in the control group received standard treatment for COPD. Patients in the intervention group were also given thymostimulin intramuscularly (1 mg/kg day for the 1st week followed by once a week for 6 months). At the end of the study period, patients treated with thymostimulin showed a statistically significant lower number of exacerbations and hospital admissions as compared with controls. However, there were no changes in the number of patients with severe or moderate impairment of respiratory function throughout the study period. No significant differences were found by Multitest or in serum concentrations of immunoglobulins and T-cell subsets before and after thymostimulin treatment. We conclude that treatment with thymostimulin is effective in the prevention of COPD exacerbations acting on the cellular immune response involved in bronchopulmonary defense.