Características sociodemográficas de los pacientes con úlceras por presión infectadas y su perfil microbiológico. Serie de casos / Sociodemographic characteristics of patients with pressure ulcers and their microbiological profile. A case series

Introducción Las ulceras por presión (UPP) son una condición frecuente en los pacientes con movilidad restringida, su sobreinfección implica un esfuerzo adicional en el tratamiento, ya que se asocia a complicaciones como osteomielitis crónica y sepsis. El objetivo del estudio es describir las características clínicas y sociodemográficas de los pacientes con UPP enfatizando en el perfil microbiológico de aquellos con sobreinfección. Materiales y métodos Se realizó un estudio descriptivo retrospectivo que incluyó a 76 pacientes adultos con diagnóstico de UPP sobreinfectadas sometidos a cirugía entre 2013 y 2015. Se obtuvo información demográfica, clínica y microbiológica. Se describieron los resultados según la naturaleza de la variable. Resultados De los 76 pacientes, 56 (73.7%) fueron hombres. La mediana de edad fue de 45 años. La mediana de hospitalización fue de 22.5 días, el principal motivo de inmovilidad fue la lesión medular (69,7%). Los patógenos más comunes fueron Enterococcus faecalis (46%), Escherichia coli (43.4%), Streptococcus spp (35.5%) y Proteus spp (30.2%). En el 77,6% de los pacientes se aislaron dos o más microorganismos en los cultivos. Discusión La lesión medular en la condición más asociada a ulceras por presión en nuestro medio, principalmente en hombres jóvenes. La sobreinfección generalmente es polimicrobiana, lo que nos muestra la gran importancia de los cultivos para poder realizar un tratamiento específico y efectivo. Al conocer las características clínicas y demográficas se pueden direccionar estrategias de prevención y rehabilitación que impacten de manera positiva en la calidad de vida de los pacientes y la sostenibilidad del sistema de salud. Nivel de evidencia IV

Background Pressure ulcers (PU) are a frequent condition in patients with restricted mobility. Their infection requires an additional effort in the treatment, since it is associated with complications, such as chronic osteomyelitis and sepsis. The aim of this study is to describe the clinical and sociodemographic characteristics of patients with PU, emphasising the microbiological profile of those with infection. Materials and methods A retrospective descriptive study was carried out on 76 adult patients diagnosed with infected PU who underwent surgery between 2013 and 2015. Demographic, clinical, and microbiological information was obtained. The results were described according to the nature of the variable. Results Of the 76 patients, 56 (73.7%) were men. The median age was 45 years. The median number of days hospitalised was 22.5 days, and the main cause of immobility was spinal cord injury (69.7%). The most common pathogens were Enterococcus faecalis (46%), Escherichia coli (43.4%), Streptococcus spp (35.5%), and Proteus spp (30.2%). Two or more microorganisms were isolated in the cultures in 77.6% of the patients, Discussion Spinal cord injury is the condition most associated with pressure ulcers in this study, mainly in young men. Infection is usually polymicrobial, which shows the great importance of the cultures, in order to be able to carry out a specific and effective treatment. By knowing the clinical and demographic characteristics, prevention and rehabilitation strategies can be directed at having a positive impact on the quality of life of PU patients, and the sustainability of the health care system. Evidence Level IV

Pressure ulcer as a reservoir of multiresistant Gram-negative bacilli: risk factors for colonization and development of bacteremia

Abstract The purpose of this study was to identify the risk factors that predispose patients who are hospitalized with pressure ulcers (PUs) colonized by Gram-negative bacilli (GNB) to develop bacteremia. In addition, we also detected main phenotypes of resistance in infected and uninfected PUs. A prospective cohort study was conducted at the Clinical Hospital of the Federal University of Uberlândia including patients with Stage II or greater PUs, colonized or not with GNB, from August 2009 to July 2010. Infected ulcers were defined based on clinical signs and on positive evaluation of smears of wound material translated by a ratio of polymorphonuclear cells to epithelial cells ≥2:1, after Giemsa staining. A total of 60 patients with Stage II PUs were included. Of these 83.3% had PUs colonized and/or infected. The frequency of polymicrobial colonization was 74%. Enterobacteriaceae and GNB non-fermenting bacteria were the most frequent isolates of PUs with 44.0% of multiresistant isolates. Among patients who had infected PUs, six developed bacteremia by the same microorganism with a 100% mortality rate. In addition, PUs in hospitalized patients were major reservoir of multiresistant GNB, also a high-risk population for the development of bacteremia with high mortality rates.

Úlceras por pressão em pacientes com lesão medular traumática: subsídios na identificação microbiológica / Úlceras por presión en pacientes con lesión traumática médula espinal: subvenciones en identificación microbiológica / Pressure ulcers in patients with traumatic spinal cord injury: subsidies in microbiological identification

Objective: To determine the prevalence of bacterial species in pressure ulcers (PU) in patients with spinal cord injury treated by a Physically Handicapped Association. Method: A descriptive, cross-sectional, quantitative study, conducted in a northeastern city from 2009 to 2010. The sample was consecutive, not probabilistic and comprised 20 individuals with spinal cord injury and PU being treated in the Association and without antibiotic therapy. Samples were collected from exudates of PU, using sterile swabs, plated on Blood Agar plates and incubated at 35°C for 24 hours. For identification of microorganisms were employed biochemical tests. Descriptive statistics were used for data analysis. Results: The six microorganisms were: S. aureus, S. epidermidis, S. saprophyticus, Proteus spp., Escherichia coli and Enterobacter spp. Conclusion: Additional prospective microbiological investigations are needed to assess the prevalence of pathogens in patients with PU injured thus instituting, nutritional, therapeutic and educational programs that reduce bacterial colonization and infection.

Objetivo: Determinar a prevalência de espécies bacterianas em úlceras por pressão (UP) de pacientes com lesão raquimedular assistidos por uma associação de deficientes físicos. Método: Estudo descritivo, transversal, quantitativo, conduzido em uma cidade nordestina de 2009 a 2010. A amostra foi consecutiva não probabilística e compreendeu 20 indivíduos com lesão raquimedular e UP, em acompanhamento na associação e sem uso de antibioticoterapia. Coletaram-se amostras de exsudatos das UP, utilizando suabes estéreis, semeadas em ágar sangue e incubadas a 35°C por 24 horas. Para identificação dos microrganismos, foram empregadas provas bioquímicas. Utilizou-se estatística descritiva para análise dos dados. Resultados: Os seis microrganismos encontrados foram: S. aureus, S. epidermides, S. saprophyticus, Proteus spp., Escherichia coli e Enterobacter spp. Conclusão: Investigações microbiológicas prospectivas adicionais são necessárias para avaliar a prevalência dos agentes patogênicos de UP em pacientes lesionados, a fim de instituir programas educacionais, nutricionais e terapêuticos que reduzam a colonização e infecção bacteriana.

Objetivo: Determinar la prevalencia de especies bacterianas en las úlceras por presión (UPP) en pacientes con lesión medular espinal (LME) tratada por una Asociación de Discapacitados Físicos. Método: Estudio descriptivo-transversal, cuantitativo, realizado en una ciudad del noreste en 2009-2010. La muestra fue no probabilística, secuencial y comprende 20 individuos con LME y UPP y sin tratamiento antibiótico. Se recogieron muestras de exudados de la UPP, utilizando torundas estériles, sembradas en placas de Agar Sangre y se incubaron a 35°C durante 24 horas. Los microorganismos fueron identificados por pruebas bioquímicas. Se utilizó estadística descriptiva para el análisis de datos. Resultados: Los seis microorganismos fueron: S. aureus, S. epidermidis, S. saprophyticus, Proteus spp, Escherichia coli y Enterobacter spp. Conclusión: Se necesitan investigaciones microbiológicas prospectivas para evaluar la prevalencia de patógenos en LME con UPP instituyendo así, los programas nutricionales, terapéuticos y educativos para reducir la colonización bacteriana y la infección.

Two Cases of Vancomycin-intermediate Staphylococcus aureus Isolated from Joint Tissue or Wound / 대한진단검사의학회지

Since its first isolation in 1997, vancomycin-intermediate Staphylococcus aureus (VISA) has been a clinical concern because it may lead to treatment failure. Up to the present, there were two reports of clinical VISA cases in Korea. We now report two additional cases of VISA with the minimum inhibitory concentration (MIC) of 4 microgram/mL. The first patient was a 59 yr-old man who had undergone total hip replacement arthroplasty in 1999 due to avascular necrosis of femur heads. He had recurrent episodes of infected hip caused by methicillin-resistant Staphylococcus aureus (MRSA) and was treated with vancomycin. He underwent replacement operation of prosthesis. Cultures of joint fluid and joint tissue grew S. aureus. Vancomycin MIC as determined by a broth microdilution method was 4 microgram/mL for the both isolates. The patient was treated with high enough doses of vancomycin to maintain serum trough concentrations at 20-25 microgram/mL for 52 days and was discharged. The second patient was a 57 yr-old man with diabetes. He lost consciousness from drinking. After recovery of consciousness, he was diagnosed with aspiration pneumonia. MRSA and Acinetobacter baumannii were cultured from sputum and the patient was treated with vancomycin and meropenem. During hospitalization, bed sores developed in his ankle and back. A wound culture from the sore grew S. aureus with vancomycin MIC of 4 microgram/mL. Since infection was localized, systemic antibiotics did not seem necessary, and the patient was transferred to another hospital for isolation and management.

Photodynamic inactivation of in vitro bacterial cultures from pressure ulcers

PURPOSE: To evaluate in vitro the antibacterial effect of diode laser light of wavelength 650 nm, in association with the photosensitive substance toluidine blue, on the bacteria in infected skin ulcers. METHODS: Samples were collected by means of swabs containing a medium for transporting infected material from skin ulcers. The material was inoculated into culturing medium containing azide blood agar for the growth of Gram-positive bacteria, and MacConkey agar for Gram-negative bacteria, and incubated for 48 hours. The results obtained from counting the colony-forming units were correlated and subjected to statistical analysis, adopting the significance level of p > or = 0.05. RESULTS: From analysis of variance (ANOVA), the result for the general mean was p = 0.0215. Using the t test with post-hoc test, the result for TBO vs. Control was p = 0.0186, and for TBO + Laser vs. Control it was p = 0.0039. CONCLUSION: There was a significant reduction in colony-forming units when the cultures were subjected to photodynamic therapy.

OBJETIVO: Avaliar in vitro o efeito antibacteriano do laser diodo com comprimento de onda de 650nn, associado a substancia fotossensível azul de toluidina sobre as bactérias de ulceras cutâneas infectadas. MÉTODOS: Foram coletadas amostras através de um swab com meio de transporte, de material infectado de úlceras cutâneas. Os materiais foram inoculadas em meios de cultura contendo ágar sangue azida para o crescimento de bactérias gram-positivas e agar Mac Conkey para as gram-negativas, e incubadas por 48 horas. Os resultados obtidos da contagem das unidades formadoras de colônias foram relacionados e submetidos a analise estatística adotando como nível de significância p > ou = 0.05. RESULTADOS: Os resultados da análise de variância ANOVA para a media geral foi p= 0,0215 e para o post hoc test teste t. TBO x Controle p=0,0186, TBO + Laser x Controle p=0,0039. CONCLUSÃO: Houve redução, significativa das unidades formadoras de colônias quando submetidas à terapia fotodinâmica.

Management of urinary tract infections, decubitus ulcer and pneumonia in the aging person

Infections in the older person are common and a significant cause of morbidity and mortality. Infections of the urinary tract, skin and soft tissue infections including decubitus ulcers, antibiotics associated diarrhea and lower respiratory tract infections are particularly important in the elderly because of their frequency. While most initial antibiotic therapy is empiric, its important before treatment to try to document the etiology for better use of antibiotics. Infections of the urinary tract are frequently and potentially serious in the elderly, they must be separated from asymptomatic bacteriuria that requires no therapy. Upper and lower urinary tract infections are frequently caused by aerobic gram negative bacilli and or enterococci. Most authors prefer the use of fluoroquinolones to manage such infections. The elderly with decubitus ulcer presents a problem in management, since these are frequent polymicrobic infections in which anaerobes play an important role. The initial therapy usually involves the combination of a fluoroquinolone plus an antianaerobic agent like clindamycin. C. difficile diarrhea as frequent in nursing home residents as well as the older person with prior antibiotics. The treatment should be with metronidazole and avoid the use of vancomycin. Pneumonias in the elderly can be acquired in the community, the nursing home or during a hospitalization. The etiologic agents that predominate change from S. pneumoniae and atypicals in those from the community to an increase in gram negative pneumonia. The initial treatment as started by most authors as well as guidelines include the use of a new fluoroquinolone like gatifloxacin alone or in combination with a beta-lactamic agent like ceftriaxone. For those infections acquired in the hospital therapy with third or fourth generation cephalosporins, carbapenems, beta-lactams with betalactamase inhibitors alone or in combination with an aminoglucoside and or vancomycin if MRSA is suspected is accepted therapy

Chronic ulcers and myasis as ports of entry for Clostridium tetani

Evaluating tetanus immune status is not yet the usual clinical practice regarding patients with chronic ulcers or myasis. However, of 858 tetanus patients at Hospital Couto Maia (Salvador, Bahia, Brazil) aged 1 year or above, 2 had pressure ulcers and 17 had chronic ulceration of the lower limbs where these skin lesions were the ports of entry for Clostridium tetani. In these 19 cases, the following predisposing factors were described: venous insufficiency (n=6), sickle cell anemia (n=2), Hansen s disease (n=1), malnutrition (n=1), diabetes mellitus (n=1), trauma (n=1) and unknown factors (n=7). In 6 other cases, in addition to the Hansen s disease patient, the port of entry for tetanus was the site of extraction of Tunga penetrans larvae. In these 25 cases, the majority of patients (68) were over 40 years old (17/25) and all of these patients stated that they had either not followed a tetanus toxoid vaccination regimen (19/25), or had partially completed such a regimen, or did not give precise information (6/25). Among the same series studied, over half (52) of the patients died (13/25). We conclude that tetanus prevention must be included in the treatment of chronic skin ulcer patients, vaccination coverage should be increased among older people, and strategies aimed at improving coverage for all age groups must be reviewed.

Análisis microbiológico de úlceras de presión en pacientes del Centro Nacional de Rehabilitación (CENARE) / Analysis microbiological the pressure sores on the National Center of the Rehabilitation (CENARE)

Justificación y objetivo: Las úlceras de presión son áreas localizadas de tejido necrótico que tienden a desarrollarse cuando los tejidos blando son comprimidos entre una prominencia ósea y una superficie externa. La principal complicación de estas lesiones es que pueden constituirse en focos primarios de infecciones bacterianas. El objetivo del presente estudio fue realizar un análisis microbilógico de las úlceras de presión en pacientes de las unidades de Lesionados Medulares, Neurotrauma y Fisiatría General del Centro Nacional de Rehabilitación para determinar cuáles bacterias aerobias predominan en dichas lesiones y determinar el perfil de susceptibilidad a los antibióticos de los aislamientos bacterianos. Métodos: En este estudio se incluyeron 50 muestras recolectadas de 35 úlceras de presión en un total de 22 pacientes con daños en la médula espinal atendidos durante el período de agosto de 1998 a marzo de 1999. Las muestras fueron cultivadas en medios convencionales para el aislamiento de bacterias aerobias. La identificación de los aislamientos se realizó mediante pruebas bioquímicas y el sistema Vitek(R). El perfil de susceptibilidad a antibióticos se realizó mediante la técnica Kirby-Bauer con respaldo por el sistema Vitek(R). Resultados: Los microorganismos más frecuentemente aislados fueron Paeroginosa, Staphylococcus coagulasanegativa, S. intermedius y A. baumannii, los cuales prestaron resistencia contra diversos antibióticos. No se encontró ningún aislamiento de Stahylococcus aureus meticilina-resistente en las lesiones estudiadas. A lo largo del estudio se observó variabilidad en los perfiles de resistencia en aislamientos de P. aeruginosa, Staphyloccus coagulasa-negativa y S. intermedius. Conclusiones: El presente estudio indica que la biota bacteriana encontrada en la úlcera de presión en pacientes con lesiones medulares del CENARE está constituida principalmente por E. aeruginosa, Staphylococcus coagulasa-negativa, S. intermedius y A. bauma...