Mortalidad en niños con bacteriemia por Stenotrophomonas maltophilia: revisión sistemática / Mortality in children with Stenotrophomonas maltophilia-related bacteremia: A systematic review

Introducción: En los niños, la bacteriemia por Stenotrophomonas maltophilia es considerada una complicación severa y asociada a una elevada mortalidad. Con el objetivo de conocer la mortalidad asociada a esa condición, se realizó una revisión sistemática de la literatura. Material y métodos: Se aplicó una estrategia de búsqueda bibliográfica con las palabras clave: bacteriemia por Stenotrophomonas maltophilia, niños y adolescentes como únicos filtros. Se informan la mediana y los valores intercuartílicos de la frecuencia de la mortalidad reportada por los estudios incluidos. Resultados: Se identificaron 165 estudios potencialmente útiles. De ellos, se seleccionaron finalmente, 9 estudios para ser incluidos. La incidencia de mortalidad a consecuencia de una bacteriemia por S.maltophilia fue del 25%; Q25: 11­Q75: 36; rango: 6,06 a 40,6. Consideraciones finales: La bacteriemia por Sm tuvo un alto porcentaje de mortalidad en especial en pacientes con patología subyacente y uso de procedimientos invasivos y el uso inadecuado de antibióticos empíricos (AU)

Introduction: In children, Stenotrophomonas maltophilia-related bacteremia is considered a severe complication associated with high mortality. With the aim to determine the mortality associated with this condition, a systematic review of the literature was conducted. Material and methods: A literature search strategy was applied using the keywords: bacteremia due to Stenotrophomonas maltophilia, children, and adolescents as the only filters. The median and interquartile ranges of the mortality rates described in the studies included are reported. Results: A total of 165 potentially useful studies were identified, of which nine were finally selected to be included in the analysis. The incidence of S.maltophilia bacteremia-related mortality was 25%; Q25: 11­Q75: 36; range: 6.06 to 40.6. Final considerations: S.maltophilia-related bacteremia was associated with a high mortality rate especially in patients with an underlying disease, when invasive procedures were performed, and when emperical antibiotics were inadequately used (AU)

Clinical and economic impact of generic versus brand name meropenem use in an intensive care unit in Colombia

Abstract Background: Recent studies suggest that sustained use of generic antibiotics may be associated with clinical failure and emergence of antibacterial resistance. The present study was designed to determine the clinical outcome between the use of generic meropenem (GM) and brand-name meropenem (BNM). Additionally, this study evaluated the economic impact of GM and BNM to determine if the former represents a cost-effective alternative to the latter. Methods: Patients treated between January 2011 and May 2014 received GM while patients treated between June 2014 and March 2017 received BNM. Mortality was compared between groups. Total infection cost was defined by the cost of antimicrobial consumption, length of stay, and laboratory and imaging exams until infection resolution. Findings: A total of 168 patients were included; survival rate for the 68 patients treated with GM was 38% compared to 59% in the patients treated with BNM. Multivariate analysis showed that the variables most strongly-associated with mortality were cardiovascular disease (OR 18.18, 95% CI 1.25-262.3, p = 0.033) and treatment with generic meropenem (OR 18.45, 95% CI 1.45-232.32, p = 0.024). On the other hand, total infection cost did not show a significant difference between groups (BNM $10,771 vs. GM $11,343; p = 0.91). Interpretation: The present study suggests that patients treated with GM have a risk of death 18 times higher compared to those treated with BNM. Furthermore, economic analysis shows that GM is not more cost effective than BNM. Summary: More studies measuring clinical outcomes are needed to confirm the clinical equivalence of brand-name versus generic antibiotics, not only for meropenem but also for other molecules.

Infection with multidrug-resistant gram-negative bacteria in a pediatric oncology intensive care unit: risk factors and outcomes / Infecção por bactérias gram-negativas multirresistentes em uma unidade de terapia intensiva pediátrica oncológica: fatores de risco e resultados

ABSTRACT OBJECTIVE: This study aimed at evaluating the predictors and outcomes associated with multidrug-resistant gram-negative bacterial (MDR-GNB) infections in an oncology pediatric intensive care unit (PICU). METHODS: Data were collected relating to all episodes of GNB infection that occurred in a PICU between January of 2009 and December of 2012. GNB infections were divided into two groups for comparison: (1) infections attributed to MDR-GNB and (2) infections attributed to non-MDR-GNB. Variables of interest included age, gender, presence of solid tumor or hematologic disease, cancer status, central venous catheter use, previous Pseudomonas aeruginosa infection, healthcare-associated infection, neutropenia in the preceding 7 days, duration of neutropenia, length of hospital stay before ICU admission, length of ICU stay, and the use of any of the following in the previous 30 days: antimicrobial agents, corticosteroids, chemotherapy, or radiation therapy. Other variables included initial appropriate antimicrobial treatment, definitive inadequate antimicrobial treatment, duration of appropriate antibiotic use, time to initiate adequate antibiotic therapy, and the 7- and 30-day mortality. RESULTS: Multivariate logistic regression analyses showed significant relationships between MDR-GNB and hematologic diseases (odds ratio [OR] 5.262; 95% confidence interval [95% CI] 1.282-21.594; p = 0.021) and healthcare-associated infection (OR 18.360; 95% CI 1.778-189.560; p = 0.015). There were significant differences between MDR-GNB and non-MDR-GNB patients for the following variables: inadequate initial empirical antibiotic therapy, time to initiate adequate antibiotic treatment, and inappropriate antibiotic therapy. CONCLUSIONS: Hematologic malignancy and healthcare-associated infection were significantly associated with MDR-GNB infection in this sample of pediatric oncology patients.

RESUMO OBJETIVO: Este estudo visou a avaliar os preditores e resultados associados às infecções por bactérias gram-negativas multirresistentes (BGN-MR) em uma unidade de terapia intensiva pediátrica oncológica (UTIP). MÉTODOS: Foram coletados dados com relação a todos os episódios de infecção por BGN que ocorreram em uma UTIP entre janeiro de 2009 e dezembro de 2012. As infecções por BGN foram divididas em dois grupos para comparação: 1) infecções atribuídas a BGN-MR e 2) infecções atribuídas a BGN não multirresistente. As variáveis de interesse incluíram idade, sexo, presença de tumor sólido ou malignidade hematológica, câncer, uso de cateter venoso central, infecção anterior por Pseudomonas aeruginosa, infecção hospitalar, neutropenia nos sete dias anteriores, duração da neutropenia, tempo de internação antes da UTI, duração da internação na UTI e uso de quaisquer dos seguintes nos 30 dias anteriores: agentes antimicrobianos, corticosteroides, quimioterapia ou radioterapia. Outras variáveis incluíram: tratamento antimicrobiano inicial adequado, tratamento antimicrobiano definitivo inadequado, duração do uso de antibióticos adequados, tempo de início da terapia antibiótica adequada, mortalidade em sete dias e mortalidade em 30 dias. RESULTADOS: As análises de regressão logística multivariada mostraram relações significativas entre as BGN-MR e as doenças hematológicas (razão de chance (RC) 5,262; intervalo de confiança de 95% (IC de 95%) 1,282-21,594; p = 0,021) e infecções hospitalares (RC 18,360; IC de 95% 1,778-189,560; p = 0,015). Houve diferenças significativas entre os pacientes com BGN-MR e BGN não MR com relação às seguintes variáveis: recebimento de terapia antibiótica empírica inicial inadequada, tempo para início do tratamento antibiótico adequado e recebimento de terapia antibiótica inadequada. CONCLUSÕES: A malignidade hematológica e a infecção hospitalar foram significativamente associadas à infecção por BGN-MR nessa amostra de pacientes pediátricos oncológicos.

Predictors of 7- and 30-day mortality in pediatric intensive care unit patients with cancer and hematologic malignancy infected with Gram-negative bacteria

Background: Infection with Gram-negative bacteria is associated with increased morbidity and mortality. The aim of this study was to evaluate the predictors of 7- and 30-day mortality in pediatric patients in an intensive care unit with cancer and/or hematologic diseases and Gram-negative bacteria infection. Methods: Data were collected relating to all episodes of Gram-negative bacteria infection that occurred in a pediatric intensive care unit between January 2009 and December 2012, and these cases were divided into two groups: those who were deceased seven and 30 days after the date of a positive culture and those who survived the same time frames. Variables of interest included age, gender, presence of solid tumor or hematologic disease, cancer status, central venous catheter use, previous Pseudomonas aeruginosa infection, infection by multidrug resistant-Gram-negative bacteria, colonization by multidrug resistant-Gram- negative bacteria, neutropenia in the preceding seven days, neutropenia duration ≥3 days, healthcare-associated infection, length of stay before intensive care unit admission, length of intensive care unit stay >3 days, appropriate empirical antimicrobial treatment, definitive inadequate antimicrobial treatment, time to initiate adequate antibiotic therapy, appropriate antibiotic duration ≤3 days, and shock. In addition, use of antimicrobial agents, corticosteroids, chemotherapy, or radiation therapy in the previous 30 days was noted. Results: Multivariate logistic regression analysis resulted in significant relationship between shock and both 7-day mortality (odds ratio 12.397; 95% confidence interval 1.291–119.016 p = 0.029) and 30-day mortality (odds ratio 6.174; 95% confidence interval 1.760–21.664 p = 0.004), between antibiotic duration ≤3 days and 7-day mortality (odds ratio 21.328 95% confidence interval 2.834-160.536; p = 0.003), and between colonization by multidrug re...

Morbimortality study of infection in patients undergoing different types of dialysis in a renal replacement therapy center

INTRODUCTION: Renal replacement therapy is the treatment of end-stage chronic kidney disease and can be performed through dialysis catheters, arteriovenous fistulas/grafts, and peritoneal dialysis. Patients are usually immunocompromised and exposed to invasive procedures, leading to high rates of infection and increased mortality. OBJECTIVES: To compare the prevalence of infection and related deaths, as well as the sensitivity profile of the putative bacteria in patients treated with peritoneal dialysis, arteriovenous fistula hemodialysis and catheter hemodialysis. METHODS: This is case-control study. Six hundred forty-four patients undergoing renal replacement therapy were selected. Patients were divided into three groups according to the modality of dialysis treatment: peritoneal dialysis (126 patients), arteriovenous fistula hemodialysis (326 patients), and catheter hemodialysis (192 patients). RESULTS: One hundred sixteen patients (18.01%) developed infection. There was a higher incidence of infection in the peritoneal dialysis group (44 patients; 34.92%; OR: 3.32; CI 95% = 2.13-5.17; p = 0.0001). In the catheter hemodialysis group, 48 patients (25%) had infection (OR: 1.88; CI 95%: 1.24-2.85; p = 0.0035). In the arteriovenous fistula hemodialysis group, 24 patients (7.36%) developed infection (OR: 0.19; CI 95%: 0.12-0.31; p = 0.0001). Five patients (4.31%) died due to infection (four in the peritoneal dialysis group and one in the catheter hemodialysis group). There were no deaths due to infection in the arteriovenous fistula hemodialysis group. CONCLUSIONS: Peritoneal dialysis is the treatment with greater risk of infection and mortality, followed by catheter hemodialysis. The lowest risk of infection and mortality was observed in arteriovenous fistula hemodialysis group. .

Factores de riesgo asociados a mortalidad en infecciones relacionadas con la atención en salud en un hospital universitario de tercer nivel en Colombia / Mortality risk factors associated with healthcare infections in a tertiary level university hospital in Colombia

Introducción. Las infecciones hospitalarias son una amenaza para la salud pública. A pesar de los esfuerzos para contenerlas, su incidencia sigue siendo grande y genera altos costos en la atención en salud. Objetivo. Determinar los factores asociados a mortalidad en pacientes con diagnóstico de infecciones hospitalarias en nuestra institución. Materiales y métodos. Se llevó a cabo un estudio prospectivo de cohortes entre enero y diciembre del 2011 por medio de la observación de 1.015 pacientes con diagnóstico de infección de acuerdo a los criterios del sistema de vigilancia hospitalaria sugeridos por los Centers for Disease Control and Prevention (CDC). Se excluyó a quienes no tenían cultivo microbiológico de la infección o habían tenido reingresos hospitalarios en menos de un año. Se evaluaron variables sociodemográficas y clínicas, perfiles de resistencia microbiológica y uso de antibióticos. La variable de desenlace fue la muerte. Se realizó un análisis de supervivencia para cada variable, estableciendo significación estadística con la prueba de log-rank , así como un análisis multivariado mediante regresión de Cox. Se consideraron significativos los valores de p menores de 0,05. Resultados. El promedio de edad fue de 43 años (57 % hombres y 43 % mujeres); 53 % de los pacientes tuvo diagnóstico clínico y 47 %, quirúrgico; 54 % de las infecciones se presentó en la herida quirúrgica y 62 % de ellas se asociaron a microorganismos Gram negativos. La mortalidad durante el seguimiento fue de 24,4 %. En el análisis multivariado se encontró asociación con mortalidad para las variables de estancia en cuidado intensivo ( hazard ratio (HR)=1,51; IC 95% 1,13-2,01), uso inapropiado de antibióticos (HR=3,05; IC 95% 2,34-3,98) y uso de antibiótico genérico o copia (HR=1,91; IC IC 95% 1,43-2,55). Conclusiones. El empleo de moléculas genéricas y el uso inadecuado de antibióticos en pacientes con infecciones hospitalarias son factores que pueden modificarse para disminuir la mortalidad.

Introduction: Nosocomial infections are a public health threat. Despite multiple efforts, its incidence is still significant and it generates high costs in health care. Objective: To determine risk factors associated with mortality in patients with healthcare infections in a tertiary level hospital in Colombia. Materials and methods: A prospective cohort observational study was performed between January and December 2011. One thousand one hundred and fifteen patients with health care infections using the CDC definition criteria were included. Exclusion criteria were those patients with no microbiologic isolate associated with the infection or hospital readmissions in the last year. Socio-demographic and clinical variables, bacterial resistance profiles and antibiotic use were evaluated. Death was the primary outcome. Survival analysis for each variable was performed using statistical significance defined by the log-rank test. Multivariate and Cox regression analyses were done. Values of p less than 0.05 were considered statistically significant. Results: Mean age was 43 years old (57% men and 47% women); 53% of patients had a medical condition and 47% surgical diagnosis; 54% of health care infections were surgical site infections and 62% were associated to Gram-negative bacilli. The mortality rate during follow-up was 24.4%. On multivariate analysis we found an association with intensive care stay (HR=1.51; 95% CI: 1.13-2.01), inappropriate use of antibiotics (HR=3.05; 95% CI: 2.34-3.98) and use of generic antibiotics or copies (HR=1.91; 95%CI: 1.43-2.55). Conclusions: The use of generic molecules of antibiotics and inappropriate antibiotic treatments in patients with health care infections are modifiable factors to decrease mortality.

Association of late-onset neonatal sepsis with late neurodevelopment in the first two years of life of preterm infants with very low birth weight / Associação de sepse neonatal tardia com atraso do neurodesenvolvimento nos primeiros dois anos de vida de recém-nascidos pré-termos de muito baixo peso

OBJECTIVE: To establish the influence of late-onset sepsis on neurodevelopment of preterm infants with very low birth weight (VLBW), according to the etiologic agent METHOD: This was a cohort of newborns with birth weight < 1,500 g and gestational age less than 32 weeks, admitted to the institutional intensive care unit (ICU) with up to 48 hours of life, and followed-up at the outpatient follow-up clinic for preterm infants with VLBW until 2 years of corrected age. Exclusion criteria: death within the first 72 hours of life, congenital malformations and genetic syndromes, children with congenital infection by the human immunodeficiency virus (HIV), congenital infection (STORCH), presence of early-onset spesis and cases with more than one pathogen growth in blood cultures. Septic and non-septic infants were compared regarding neonatal outcomes and mortality. Neurodevelopment was assessed using the Bayley Scale (BSDI-II) at 18 to 24 months of corrected age. RESULTS: 411 preterm infants with VLBW were eligible; the mean gestational age was 29 ± 2.2 weeks and mean birth weight was 1,041 ± 281grams. Late-onset sepsis occurred in 94 preterm infants with VLBW (22.8%). VLBW infants with Gram-positive infection showed motor deficit when compared to the non-septic group, 68.8% vs. 29.3%, respectively (OR 6; 1.6-21.8, p = 0.006); the cognitive development was similar between the groups. The overall mortality rate from infection was 26.7%; considering the pathogens, the rates were 18.7% for coagulase-negative Staphylococcus, 21.8% for Gram-positive bacteria, and 50% for Gram-negative bacteria and fungi. CONCLUSION: Neonatal sepsis has a significant influence on late neurodevelopment at 2 years of corrected age in preterm infants with VLBW, and Gram-positive infections are associated with motor deficit. .

OBJETIVO: Estabelecer a influência da sepse tardia no neurodesenvolvimento de prematuros de muito baixo peso (MBP) recém-nascidos (RNs) de acordo com o agente etiológico. MÉTODOS: Coorte de RN com peso de nascimento < 1.500 g e idade gestacional < 32 semanas,internados na UTI da instituição dentro de 48 horas de vida, e atendidos no ambulatório de MBP para até dois anos de idade corrigida. Foram excluídos: a morte nas primeiras 72 h de vida, malformações congênitas e síndromes genéticas, filhos de mães HIV-positivas e infecção congênita, presença de sepse precoce, e os casos com mais de um microorganismo identificado em hemoculturas. RNs sépticos e não sépticos foram comparados quanto resultados neonatais, mortalidade e neurodesenvolvimento avaliados através das escalas Bayley (BSDI-II) aos 18-24 meses de idade corrigida. RESULTADOS: Um total de 411 RNs prematuros de muito baixo peso eram elegíveis, com idade gestacional = 29 ± 2,2 semanas e peso de nascimento = 1.041 ± 281 g. Sepse tardia ocorreu em 94 casos (22,8%). MBP RN com infecção causada por microrganismos Gram-positivos apresentaram atraso motor, quando comparado com o grupo sem sépsis - 68,8% vs 29,3% (OR 6; 1,6-21,8,p = 0,006), e atraso cognitivo, foi semelhante. Taxa de mortalidade global de infecção foi de 26,7%, e as taxas de mortalidade por grupo microorganismo foram: Staphylococcus coagulase negativa, 18,7%; Gram-positivos, 21,8%; Gram-negativas e fungos, 50%. CONCLUSÃO: A sepse neonatal tem uma influência significativa no atraso no desenvolvi mento neuropsicomotor aos dois anos de idade corrigida em prematuros de muito baixo peso RN e as infecções por germes gram-positivos estão associadas com atraso motor. .

Colistina parenteral no tratamento de infeccoes graves: experiencia em centro unico / Parenteral colistin for the treatment of severe infections: a single center experience

Objetivo: Descrever a experiência de um único centro com o uso de colistina para tratar infecções hospitalares causadas por bactérias Gram-negativas resistentes a múltiplos fármacos e identificar fatores associados com lesão renal aguda e mortalidade. Métodos: Estudo longitudinal retrospectivo que avaliou pacientes gravemente enfermos, com infecções causadas por bactérias Gram-negativas resistentes a múltiplos fármacos. Foram considerados elegíveis para este estudo, durante o período compreendido entre janeiro e dezembro de 2008, todos os pacientes adultos com necessidade de tratamento com colistina endovenosa (colistimetato de sódio). As informações coletadas incluem dados demográficos, diagnóstico, duração do tratamento, presença de lesão renal aguda e mortalidade em 30 dias. Resultados: A colistina foi utilizada para tratar uma infecção em 109 de 789 pacientes (13,8%) admitidos à unidade de terapia intensiva. A mortalidade em 30 dias observada nestes pacientes foi de 71,6%. Vinte e nove pacientes (26,6%) tinham lesão renal prévia ao tratamento com colistina, sendo que seis deles conseguiram recuperar a função renal, mesmo durante o tratamento com colistina. Vinte e um pacientes (19,2%) desenvolveram lesão renal aguda durante o tratamento com colistina, sendo que 11 destes pacientes necessitaram ser submetidos à diálise. A variável independentemente associada com a presença de lesão renal aguda foi a pontuação segundo o sistema Sequential Organ Failure Assessment no início do tratamento com colistina (OR=1,46; IC95%=1,20-1,79; p<0,001). Idade (OR=1,03; IC95%=1,00-1,05; p=0,02) e uso de vasopressores (OR=12,48; IC95%=4,49-34,70; p<0,001) foram fatores associados a óbito, segundo um modelo de regressão logística. ...

Objective: To describe a single center experience involving the administration of colistin to treat nosocomial infections caused by multidrug-resistant Gram-negative bacteria and identify factors associated with acute kidney injury and mortality. Methods: This retrospective longitudinal study evaluates critically ill patients with infections caused by multidrug-resistant Gram-negative bacteria. All adult patients who required treatment with intravenous colistin (colistimethate sodium) from January to December 2008 were considered eligible for the study. Data include demographics, diagnosis, duration of treatment, presence of acute kidney injury and 30-day mortality. Results: Colistin was used to treat an infection in 109 (13.8%) of the 789 patients admitted to the intensive care unit. The 30-day mortality observed in these patients was 71.6%. Twenty-nine patients (26.6%) presented kidney injury prior to colistin treatment, and six of these patients were able to recover kidney function even during colistin treatment. Twenty-one patients (19.2%) developed acute kidney injury while taking colistin, and 11 of these patients required dialysis. The variable independently associated with the presence of acute kidney injury was the Sequential Organ Failure Assessment at the beginning of colistin treatment (OR 1.46; 95%CI 1.20-1.79; p<0.001). The factors age (OR 1.03; 95%CI 1.00-1.05; p=0.02) and vasopressor use (OR 12.48; 95%CI 4.49-34.70; p<0.001) were associated with death in the logistic-regression model. Conclusions: Organ dysfunction at the beginning of colistin treatment was associated with acute kidney injury. In a small group of patients, we were able to observe an improvement of kidney function during colistin treatment. Age and vasopressor use were associated with death. .

Factors influencing the early mortality in haematological malignancy patients with nosocomial Gram negative bacilli bacteraemia: a retrospective analysis of 154 cases

BACKGROUND: The aim of this study is to assess the factors influencing the early mortality (7- day after index blood culture) in haematological malignancy patients with Gram negative bacilli (GNB) bacteraemia. METHODS: Infection control committee records were reviewed to identify the cases between March 2006 and June 2011. Only one bacteraemic episode per patient was included in the study. RESULTS: A total of 154 patients with GNB bacteraemia were identified. The early mortality rate was 19.5% (30 out of 154). Blood cultures revealed Enterobacteriacea in 120 patients (Escherichia coli; 86, Klebsiella spp.; 28, Enterobacter cloacea; 6) and glucose non-fermenting GNB in 34 patients (Pseudomonas aeruginosa; 15, Acinetobacter baumannii; 11, Stenotrophomonas maltophilia; 7, Burkholderia cepacia; 1). Forty (33.3%) out of 120 Enterobacteriaceae were extended spectrum beta-lactamase (ESBL) producers and 18 (52.9%) out of 34 glucose non-fermenting GNB were multidrug resistant. Carbapenems were administered as first line therapy in 139 out of 154 patients. In univariate analysis Pitt's bacteraemia score, presence of aplastic anaemia, bacteraemia caused by glucose non-fermentating GNB, inappropriate empirical antibacterial treatment, presence of severe sepsis or septic shock, unable to achieve microbiological cure, and intensive care unit (ICU) acquired bacteraemia were associated with mortality. Multivariate analysis showed ICU acquired bacteraemia (OR, 12.55; 95% CI, 2.34-67.38, p = 0.003) as an independent factor associated with early mortality. CONCLUSION: Haematological malignancy patients who require ICU care are at high risk for early mortality related to GNB bacteraemia. Based on the local findings pointing out high rate of multidrug resistance, carbapenems combined with colistin seems to be a reasonable approach as empirical treatment of these patients. However, increasing carbapenem resistance rate is of concern.

Colangitis bacteriémica en adultos en un hospital general en Chile / Bacteremic colangitis in adults in a general hospital in Chile

Background: Some aspects of bacteremic cholangitis are unknown in Chile. Aim: To gather more information on clinical, microbiological aspects as well as risk factors for ICU admission, recurrence and antimicrobial resistance. Material and Methods: A retrospective research was performed using medical records of adult patients in a general hospital. Results: Between 2006-2012, 22 patients with 29 bacteremic events were identified. Previous cholangitis events were reported by 27.3%, 45.5% had recent admissions and, 50% had used antimicrobial compounds. Coledocholithiasis was the most common cause of obstruction (45.5%) followed by cancer (36.4%). One third developed shock (31%), the only factor associated with ICU admission (OR 30, p < 0.05). In 24 of the 29 bacteremic events, the biliary tract was intervened (82.8%) and in 80.8% during the first 72 hours. Gram negative bacilli were predominant (> 80%) and some infrequent agents such as Staphylococcus warneri, Shewanella spp. and, Aeromonas spp. were observed. Among enteric gram negative bacilli, 29.2% presented fluoroquinolone resistance and, 26.1% resistance to third generation cephalosporins, both associated with previous endoscopic retrograde cholangiography (OR 35 and 16.5, respectively p < 0.05). A favorable response was observed in 93.1% of bacte-remic events but in 31.8% of patients cholangitis recurred with or without bacteremia. Recurrence was associated to recent admission (OR 16.5, p = 0.01) and in all cases occurred before 81 days. In-hospital mortality was 9.1% (n = 2), but in only one case associated to sepsis. Average length of stay (LOS) was 17.8 days. Conclusions: Early intervention of the biliary tract allows a favorable response in patients affected by bacteremic cholangitis, but this condition use intensive care resources, had a prolonged LOS, a recurrent pattern, and is associated with several bacterial species, some of them resistant.

Introducción: La información sobre los cuadros de colangitis aguda bacteriémica es fragmentaria en Chile. Objetivo: Analizar las características clínicas, evolución, microbiología y factores de riesgo asociados a ingreso a UCI, recurrencia y resistencia antimicrobiana. Pacientes y Métodos: Estudio retrospectivo descriptivo con adultos atendidos entre el 2006 y el 2012 en un hospital general. Resultados: Se identificaron 22 pacientes con 29 episodios de bacteriemia. Un 27,3% tenía historia previa de colangitis aguda, 45,5% de hospitalizaciones en los últimos tres meses y 50% recibió previamente antimicrobianos. La coledocolitiasis fue la causa más frecuente de obstrucción (45,5%) y las neoplasias ocuparon el segundo lugar (36,4%). El 31% desarrolló shock hemodinámico y fue el factor determinante para ingresar a la UCI (OR 30, p < 0,01) En 24 de los 29 eventos de colangitis bacteriémica se efectuaron intervenciones sobre la vía biliar (VB) o complicaciones asociadas (82,8%), las que se realizaron predominantemente en las primeras 72 h de hospitalización (80,8%). Las especies bacterianas mayoritarias fueron bacilos gramnegativos entéricos o no fermentadores (> 80% del total) y se observaron agentes inusuales como Staphylococcus warneri, Shewanella spp y Aeromonas spp. Entre los bacilos gramnegativos entéricos, 29,2% presentó resistencia a fluoroquinolonas y 26,1 % a cefalosporinas de tercera generación, fenómenos asociados al antecedente de colangiografía endoscópica retrógrada (OR 35 y 16,5 respectivamente, p < 0,05). El 93,1% de los eventos de bacteriemia tuvo una respuesta favorable pero 31,8% de los pacientes presentó recu-rrencia de colangitis, con o sin bacteriemia, un hecho asociado a hospitalización reciente (OR 16,5, p = 0,01) y que se dio en todos los casos antes de 81 días. Dos pacientes con cáncer fallecieron en la misma hospitalización (9,1%), aunque uno solo de ellos en forma atribuible a la infección. La estadía hospitalaria promedio fue de 17,8 días. Conclusiones: Con la intervención precoz sobre la VB, los cuadros de colangitis bacteriémica han logrado una baja letalidad pero usan recursos intensivos, tienen una estadía prolongada, un patrón recurrente, pueden estar asociados a cáncer y a una diversidad de agentes bacterianos, algunos de ellos resistentes.

Bacteriemia en daño hepático crónico / Bacteremia in patients with liver cirrhosis

Las infecciones bacteriémicas son más frecuentes en el paciente cirrótico que en la población general. Se identificaron retrospectivamente 59 pacientes cirróticos con bacteriemia, hospitalizados entre los años 2005 y 2008. La bacteriemia sin foco fue la más frecuente (29 por ciento), seguida de aquellas de origen pulmonar (22 por ciento). Cincuenta y dos por ciento de los agentes aislados correspondieron a cocáceas grampositivas y 48 por ciento a bacilos gramnegativos, siendo estos últimos los agentes predominantes en las bacteriemias nosocomiales. Los principales agentes aislados fueron Staphylococcns aureus (24 por ciento) y Escherichia col i (22 por ciento). La mortalidad de los pacientes cirróticos bacteriémicos fue mayor que la del total de cirróticos hospitalizados (37 vs 9,4 por ciento; p < 0,001) y la medición del puntaje de MELD a las 72 horas se correlacionó significativamente con la mortalidad. Conclusión: La bacteriemia es una complicación grave del paciente cirrótico y el MELD podría ser útil en su categorización de riesgo.

Bacteremic infections are more frequent in patients with cirrhosis, as their immune system is compromised. Series of cirrhotic patients with bacteremia has seldom been reported in Chile. We retrospectively collected, from 2005 to 2008, 59 episodes of bacteremia in cirrhotics representing 9 percent of the overall number of bacteremic episodes seen in our center in the period. Spontaneous bacteremia accounted for 29 percent followed by those of pulmonary origin (22 percent). Grampositive cocci and gramnegative bacilli were responsible in 52 percent and 48 percent respectively, however gramnegative rods predominated in nosocomial bacteremias. Overall, the most frequent organisms were Staphylococcus aureus (24 percent) and Escherichia col i (22 percent). Mortality in bacteremic patients was significantly higher compared with all cirrhotic patients hospitalized in the period (37.0 vs 9.4 percent; p < 0.001) and MELD score was significantly correlated with mortality. Conclusion: bacteremia is a severe complication of cirrhosis and MELD score could be a useful tool to stratify risk in these patients.

Neonatal meningitis according to the microbiological diagnosis: a decade of experience in a tertiary center / Meningite neonatal de acordo com diagnóstico microbiológico: uma década de experiência em centro terciário

The aim of this study was to evaluate the incidence of and mortality due to meningitis and compare data according to microbiological diagnosis. This was a ten-year retrospective study conducted at a neonatal intensive care unit (NICU). Newborns with meningitis confirmed by positive CSF culture were included; those with congenital infection or malformations that made lumbar puncture impossible were excluded. The variables investigated were birth weight, gestational and postnatal age, procedures, hematological and CSF parameters, and complications. Parametric and non-parametric tests were used (statistical value p<0.05). The incidence of meningitis was 0.6 percent and mortality was 27 percent. Of the 22 cases, 59 percent involved Gram-negative bacteria; 36 percent Gram-positive and 5 percent fungi. The groups did not differ in relation to birth weight, gestational and postnatal age, procedures or hematological and CSF parameters. Sepsis, convulsions and deaths were frequent in both groups, without statistical difference. Gram-negative cases showed abscesses and higher frequency of ventriculitis and hydrocephaly. Meningitis was infrequent, but presented high mortality and frequent complications.

O objetivo do estudo foi avaliar incidência e mortalidade da meningite e comparar dados de acordo com o diagnóstico microbiológico. Estudo retrospectivo, de 10 anos, em UTI Neonatal. Incluídos RNs com meningite confirmada por cultura de líquor positiva; RN com infecção congênita ou malformações que impedem punção lombar foram excluídos. Variáveis: peso ao nascimento, idades gestacional e pós natal, procedimentos, parâmetros hematológicos e liquóricos, complicações. Testes paramétricos e não paramétricos foram utilizados (valor estatístico p<0,05). A incidência de meningite foi de 0,6 por cento e mortalidade de 27 por cento. Dos 22 casos, 59 por cento foram por bactérias Gram-negativas; 36 por cento por bactérias Gram-positivas e 5 por cento por fungos. Grupos não diferiram quanto ao peso ao nascimento, idades gestacional e pós-natal, procedimentos e por parâmetros hematológicos e liquóricos. Sepse, convulsões e óbitos foram frequentes e não diferiram entre os grupos. Gram-negativos causaram abscessos e mais frequentemente ventriculite e hidrocefalia. Meningite não foi freqüente, mas apresentou alta mortalidade e complicações.

Epidemiología y factores de riesgo de mortalidad de las bacteriemias intrahospitalarias por bacilos gramnegativos / Nosocomial bloodstream infections caused by gram-negative bacilli: epidemiology and risk factors for mortality

Nosocomial bacteremia is a major cause of hospital infection, associated with high rate of morbidity and mortality, prolonged hospital stay and higher costs. However, few prospective studies analyse the prognostic factors associated with mortality of gramnegative rods bloodstream infections in hospital wards outside of intensive care units. A prospective/descriptive study was conducted from March to December 2006. All patients with nosocomial-acquired bloodstream infection due to gramnegative rods were included. Epidemiology and clinical features were analysed as potential prognostic factors for mortality. During the study period, 84 cases were detected, being A. baumannii, Burkholderia sp and E. coli the most frequent isolates, with a mortality of 48 percent>. Bacteremia derived from a high-mortality associated septic focus (RR 4.9, IC95 percent> 1.3 - 18.8) and admissionto intensive care unit (RR 4.78, IC95 percent> 1.7- 13.1) were independent variables associated with mortality. Inappropriate empirical antibiotic treatment was not associated with greater risk of mortality. Nosocomial gramnegative bloodstream infections in our series were mainly due to non-fermentative bacilli and were associated with high mortality rates when their origin was a high risk septic focus or the patient was admitted to intensive care unit.

La bacteriemia nosocomial es una causa importante de infección intrahospitalaria, asociada a alta morbi-mortalidad, pero pocos estudios examinan en forma prospectiva las bacteriemias por bacilos grammne-gativos (BGN) más allá de las áreas de cuidados intensivos. Se realizó un estudio descriptivo, prospectivo desde marzo a diciembre del 2006, reclutando todos los pacientes con bacteriemia por BGN de origen intra-hospitalario. Se analiza la epidemiología y características clínicas como potenciales factores pronósticos de mortalidad. En el período de estudio se detectaron 84 casos (los más frecuentes A. baumannii, Burkholderia sp. y E. coli), con una mortalidad de 48 por ciento. La bacteriemia derivada de un foco infecciosos asociada a alta mortalidad (RR 4.9, IC95 por ciento 1,3-18,8) y la internación en UCI (RR 4,78, IC95 por ciento 1,7-13,1) fueron variables independientes predictoras de mortalidad. El tratamiento antimicrobiano empírico inadecuado no se asoció a mayor mortalidad. La bacteriemia nosocomial por BGN en nuestra serie se debió principalmente a bacilos no fermentadores y ésta se asoció con alta mortalidad cuando el origen fue un foco de alto riesgo o el paciente se encontraba internado en la UCI.

Risk factors for nosocomial bloodstream infection caused by multidrug resistant gram-negative bacilli in pediatrics

The aim of this study was to identify the risk factors for nosocomial bloodstream infections by multidrug resistant Gram-negative bacilli. From November 2001 to December 2003, in the Pediatric Department of the Santa Casa de São Paulo, a retrospective case-control study was developed concerning patients who had nosocomial bloodstream infection caused by Gram-negative bacilli. Patients with multidrug resistant infections were designated as case patients, and control patients were those with an infection that did not meet the criteria for multidrug resistance. Previous use of central venous catheter and previous use of vancomycin plus third generation cephalosporins were associated to a higher chance of infections by multidrug resistant Gram-negative bacilli (Odds ratio - 5.8 and 5.2, respectively). Regarding sensitivity of the isolated agents, 47.8 percent were multidrug resistant, 54.2 percent were Klebsiella spp. ESBL producers and 36.4 percent were imipenem resistant Pseudomonas aeruginosa. The lethality rate was 36.9 percent in the studied cases and this rate was significantly higher in the group of patients with multidrug resistant infections (p=0.013). Risk factor identification as well as the knowledge of the susceptibility of the nosocomial infectious agents gave us the possibility to perform preventive and control strategies to reduce the costs and mortality related to these infections.

Sepse grave e choque séptico em crianças com câncer: fatores preditores de óbito / Severe sepsis and septic shock in children with cancer

OBJETIVO: Descrever as características clínicas das crianças e adolescentes portadores de doenças oncológicas que foram admitidos na UTIP apresentando sepse grave ou choque séptico. E determinar os fatores preditores de óbito e uso de ventilação pulmonar mecânica (VPM). MÉTODOS: Foram analisadas prospectivamente 33 crianças com diagnóstico de sepse grave ou choque séptico, na UTIP do Hospital do Câncer, entre junho e dezembro de 2001. RESULTADOS: Durante o período houve 33 internações, cuja idade variou entre 1 e 23 anos; 16 (48 por cento) eram do sexo masculino e 17 (52 por cento) do sexo feminino. Vinte pacientes eram portadores de leucemia ou linfoma e 13 pacientes de tumores sólidos. Vinte e oito pacientes apresentaram quadro infeccioso documentado. Houve crescimento de patógenos em 73 por cento, sendo que as infecções por germes gram-negativos foram responsáveis por 67 por cento das amostras. Suporte respiratório foi necessário em 18 casos (54 por cento), a administração de drogas inotrópicas em 22 casos (67 por cento) e em quatro casos a diálise foi indicada. A taxa de mortalidade foi de 41 por cento para os pacientes que necessitaram de drogas inotrópicas, 69 por cento para os que utilizaram VPM e 100 por cento para aqueles submetidos à diálise. A taxa de mortalidade foi de 27 por cento. CONCLUSÕES: Nossos dados sugerem que o início precoce de tratamento intensivo para crianças com câncer apresentando sepse grave e choque séptico pode ser um fator capaz de influenciar a mortalidade desses pacientes. E a utilização da ventilação pulmonar mecânica não invasiva demonstrou ser um procedimento capaz de reduzir a necessidade de intubação orotraqueal e ventilação pulmonar mecânica invasiva.

Factores pronóstico y mortalidad asociada a bacteremias por bacilos gramnegativos / Mortality and prognostic factors associated to gramnegative bacillus bacteremia

La frecuencia de bacteremia por bacilos gramnegativos ha aumentado en forma importante en este siglo. La mortalidad asociada a este tipo de infecciones es alta y los factores asociados a éstas son múltiples. Realizamos un estudio retrospectivo, en el que se analizan diferentes factores relacionados con el huésped, el bacilo y el hospital que pudieran afectar la evolución del paciente. Se mostro que las bacteremias por Stenotrophomona maltophilia, el antecedente de neoplasia, el uso previo de carbapenémicos y el uso de nutrición parenteral total se asociaron a mayor mortalidad