Malaria grave en mujeres gestantes hospitalizadas entre el 2010 y el 2014 en el departamento de Antioquia, Colombia / Severe malaria in pregnant women hospitalized between 2010 and 2014 in the Department of Antioquia (Colombia)

Resumen Introducción. La malaria (o paludismo) durante la gestación impacta negativamente la salud de la madre y del neonato, con alto riesgo de complicaciones clínicas y mortalidad. En las regiones de alta endemia se han caracterizado, especialmente, la anemia materna y el bajo peso al nacer, pero es poco conocido el espectro clínico en las zonas de baja endemia. Objetivo. Caracterizar clínica y epidemiológicamente los episodios de malaria en mujeres gestantes hospitalizadas en el departamento de Antioquia entre el 2010 y el 2014. Materiales y métodos. Se hizo un estudio descriptivo, transversal y retrospectivo, con historias clínicas de mujeres gestantes con malaria por Plasmodium falciparum y P. vivax. Se utilizaron los criterios diagnósticos de malaria complicada de la Organización Mundial de la Salud (OMS) y de la Guía para la atención clínica integral del paciente con malaria vigente en Colombia. Resultados. Se analizaron 111 casos; el 13,5 % se clasificó como complicación grave según los criterios de la OMS, porcentaje que ascendió a 23,4 % según los criterios de la guía colombiana. Las complicaciones detectadas fueron disfunción hepática, anemia, acidosis y trombocitopenia grave. No se observó diferencia en la frecuencia de las complicaciones según la especie de plasmodio. El 39,4 % de los casos presentó signos generales de peligro; la palidez y la ictericia fueron los más frecuentes. El 40,5 % presentó signos de peligro para la gestación como la cefalea persistente, el dolor abdominal y el sangrado vaginal. Conclusiones. La malaria grave se presenta con gran frecuencia en las mujeres gestantes, sin diferencia según la especie de plasmodio, y se manifiesta con signos de peligro precozmente reconocibles. Se encontró un subregistro hospitalario del 88 % de los casos graves y falta de exámenes de laboratorio para un diagnóstico más completo. Se requiere un protocolo para el diagnóstico clínico de las mujeres gestantes con malaria.

Abstract Introduction: Malaria during pregnancy has a negative impact on maternal-neonatal health, with a high risk of clinic complications and mortality. High endemic areas are specially characterized by maternal anaemia and low birth weight. The clinical spectrum is little known in low endemic areas. Objective: To clinically and epidemiologically characterize malaria episodes in hospitalized pregnant women in the Department of Antioquia (Colombia) in the period 2010-2014. Materials and methods: Retrospective, cross-sectional, descriptive study with medical records of pregnant women with P. falciparum and P. vivax malaria. The WHO severe malaria diagnostic criteria and the Colombian Guía para la atención clínica integral del paciente con malaria (guidelines for comprehensive malaria treatment) were used. Results: We analyzed 111 cases, out of which 13.5% were classified as severe malaria according to the WHO criteria. Following the Colombian Guidelines, the proportion increased to 23.4%. Identified complications included hepatic dysfunction, anaemia, acidosis, and severe thrombocytopenia. No difference in the frequency of complications by Plasmodium species was observed; 39.4% of the cases presented general danger signs, pallor and jaundice being the most frequent; 40.5% showed danger signs for pregnancy, such as persistent headache, abdominal pain, and vaginal bleeding. Conclusions: Severe malaria is a highly frequent event in pregnant women, without differences by Plasmodium species. It shows early recognizable dangers signs. Hospital under-reporting was identified in 88% of severe cases as well as a lack of laboratory tests for a more comprehensive diagnosis. A protocol for the clinical diagnosis of pregnant women with malaria is required.

Third-generation cephalosporin resistance of community-onset Escherichia coli and Klebsiella pneumoniae bacteremia in a secondary hospital

BACKGROUND/AIMS: To enable appropriate antimicrobial treatment for community-onset infections in emergency departments (EDs), data are needed on the resistance profiles of Escherichia coli and Klebsiella pneumoniae, which are the main pathogens of community-onset bacteremia. METHODS: Records were reviewed of 734 patients with E. coli and K. pneumoniae bacteremia who visited the Daegu Fatima Hospital ED, Daegu, Korea between 2003 and 2009. We investigated the demographic data, clinical findings, and antimicrobial susceptibility patterns of the organisms. RESULTS: Of 1,208 cases of community-onset bacteremia, 62.8% were caused by E. coli or K. pneumoniae in an ED of a secondary care hospital. Five hundred and forty-eight cases of E. coli (75%) and 183 cases of K. pneumoniae (25%) were analyzed. Urinary tract infection (43.1%) was most common, followed by intra-abdominal infection (39%) and pneumonia (7.2%). Trimethoprim/sulfamethoxazole, fluoroquinolone, third-generation cephalosporin (3GC) and amikacin resistance rates among E. coli and K. pneumoniae were 22.8%, 19.6%, 6.2%, and 1.3%, respectively. In 2009, the rate of 3GC resistance (10.6%) was significantly higher, compared to the annual averages of 2003 to 2008 (6.1%; p = 0.03). Previous exposure to antibiotics was an independent risk factor for 3GC resistance in multivariate logistic regression analysis. CONCLUSIONS: The rate of 3GC resistance increased in community-onset infections, and previous exposure to antibiotics was an independent risk factor. Despite the increased 3GC resistance in community-onset infections, an amikacin combination therapy could provide an option for treatment of bacteremic patients with previous antibiotic exposure in an ED.

Referral and counter-referral system between secondary and tertiary care facilities in a children's hospital network of Greater Buenos Aires / Sistema de referencia-contrarreferencia entre el segundo y el tercer nivel de salud en una red hospitalaria pediátrica en el conurbano bonaerense

Introduction. Hospital El Cruce is a tertiary care facility which is part of a healthcare network that has been operating since July 2008 and includes health centers from five municipalities of the South of Greater Buenos Aires. The objective of the study was to describe the referral and counter-referral system at the pediatric intermediate medical care unit of the Hospital El Cruce, the tertiary level care of the network, and secondly to identify the critical points that could go against the consolidation of the network and to analyze the level of knowledge about it. Population and Methods. This was a cross-sectional, prospective study conducted at the pediatric intermediate medical care unit of Hospital El Cruce between July 2008 and December 2010. Indicators related to patient admission and discharge were analyzed. A survey was administered to all the heads of the network's pediatric departments in order to assess the level of knowledge they had about it. Results. A total of1677patients were hospitalized; 83.9% were referred from the network. Of all referrals made, 71.1% were accepted. There were 156 patients (9.4%) who were counter-referred to the referring facility. The survey results showed that 70% of heads of pediatric departments were unaware of the range of services provided by the network. Conclusions. Health care exchange was predominantly based on accepting patients referred from secondary care facilities to Hospital El Cruce and a minimum number of counter-referrals to referring facilities, with a radial pattern dynamics. There was scarce knowledge about the availability of the network health service delivery.

Introducción. El Hospital El Cruce es un centro de alta complejidad de una red asistencial que funciona desde julio de 2008 y abarca centros sanitarios de cinco municipios del conurbano sur bonaerense. El objetivo del estudio fue describir el sistema de referencia y contrarreferencia a la unidad de cuidados intermedios pediátricos del Hospital de Alta Complejidad en Red El Cruce, y secundariamente identifcar los puntos críticos que podrían conspirar contra la consolidación de la red y analizar el nivel de autoconocimiento sobre ésta. Población y métodos. Estudio observacional, prospectivo, realizado en la unidad de cuidados intermedios pediátricos del Hospital El Cruce, entre julio de 2008 y diciembre de 2010. Se analizaron los indicadores vinculados al ingreso y egreso del paciente. Se realizó una encuesta a todos los jefes de servicios pediátricos de la red para evaluar el nivel de conocimiento sobre ésta. Resultados. Se internaron 1677 pacientes; 83,9% fueron derivados desde la red. Se aceptaron 71,1% de las derivaciones solicitadas. El 9,4% (156 pacientes) fueron contrarreferidos al centro de origen. En la encuesta, 70% de las respuestas de los jefes de servicios pediátricos expresaron desconocimiento del menú prestacional de la red. Conclusiones. El intercambio asistencial se basó predominantemente en la aceptación de pacientes derivados desde centros de segundo nivel de atención hacia el Hospital El Cruce y escasa contrarreferencia hacia los centros derivadores, con una dinámica de funcionamiento radiada. Hubo escaso conocimiento de la disponibilidad de prestaciones de la red.