Knowledge, attitudes and perceptions of Latin American healthcare workers relating to antibiotic stewardship and antibiotic use: a cross-sectional multi-country study.

BACKGROUND: The burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers' (HCWs) knowledge, attitudes, and perceptions of antimicrobial stewardship (AS), AMR, and antibiotic use (AU) in the region. METHODS: HCWs from 42 hospitals from 5 Latin American countries were invited to take an electronic, voluntary, anonymous survey regarding knowledge, attitudes, and perceptions of AS, AMR, and AU between March-April 2023. FINDINGS: Overall, 996 HCWs completed the survey (52% physicians, 32% nurses, 11% pharmacists, 3% microbiologists, and 2% "other"). More than 90% of respondents indicated optimizing AU was a priority at their healthcare facility (HCF), 69% stated the importance of AS was communicated at their HCF, and 23% were unfamiliar with the term "antibiotic stewardship". Most (> 95%) respondents acknowledged that appropriate AU can reduce AMR; however, few thought AU (< 30%) or AMR (< 50%) were a problem in their HCF. Lack of access to antibiogram and to locally endorsed guidelines was reported by 51% and 34% of HCWs, respectively. Among prescribers, 53% did not consider non-physicians' opinions to make antibiotic-related decisions, 22% reported not receiving education on how to select antibiotics based on culture results and 60% stated patients and families influence their antibiotic decisions. CONCLUSIONS: Although HCWs perceived improving AU as a priority, they did not perceive AU or AMR as a problem in their HCF. AS opportunities include improved access to guidelines, access to AMR/AU data, teamwork, and education on AS for HCWs and patients and families.

Efficacy of three benznidazole dosing strategies for adults living with chronic Chagas disease (MULTIBENZ): an international, randomised, double-blind, phase 2b trial.

BACKGROUND: Treatment with benznidazole for chronic Chagas disease is associated with low cure rates and substantial toxicity. We aimed to compare the parasitological efficacy and safety of 3 different benznidazole regimens in adult patients with chronic Chagas disease. METHODS: The MULTIBENZ trial was an international, randomised, double-blind, phase 2b trial performed in Argentina, Brazil, Colombia, and Spain. We included participants aged 18 years and older diagnosed with Chagas disease with two different serological tests and detectable T cruzi DNA by qPCR in blood. Previously treated people, pregnant women, and people with severe cardiac forms were excluded. Participants were randomly assigned 1:1:1, using a balanced block randomisation scheme stratified by country, to receive benznidazole at three different doses: 300 mg/day for 60 days (control group), 150 mg/day for 60 days (low dose group), or 400 mg/day for 15 days (short treatment group). The primary outcome was the proportion of patients with a sustained parasitological negativity by qPCR during a follow-up period of 12 months. The primary safety outcome was the proportion of people who permanently discontinued the treatment. Both primary efficacy analysis and primary safety analysis were done in the intention-to-treat population. The trial is registered with EudraCT, 2016-003789-21, and ClinicalTrials.gov, NCT03191162, and is completed. FINDINGS: From April 20, 2017, to Sept 20, 2020, 245 people were enrolled, and 234 were randomly assigned: 78 to the control group, 77 to the low dose group, and 79 to the short treatment group. Sustained parasitological negativity was observed in 42 (54%) of 78 participants in the control group, 47 (61%) of 77 in the low dose group, and 46 (58%) of 79 in the short treatment group. Odds ratios were 1·41 (95% CI 0·69-2·88; p=0·34) when comparing the low dose and control groups and 1·23 (0·61-2·50; p=0·55) when comparing short treatment and control groups. 177 participants (76%) had an adverse event: 62 (79%) in the control group, 56 (73%) in the low dose group, and 59 (77%) in the short treatment group. However, discontinuations were less frequent in the short treatment group compared with the control group (2 [2%] vs 11 [14%]; OR 0·20, 95% CI 0·04-0·95; p=0·044). INTERPRETATION: Participants had a similar parasitological responses. However, reducing the usual treatment from 8 weeks to 2 weeks might maintain the same response while facilitating adherence and increasing treatment coverage. These findings should be confirmed in a phase 3 clinical trial. FUNDING: European Community's 7th Framework Programme.

Deep Dive Into Gaps and Barriers to Implementation of Antimicrobial Stewardship Programs in Hospitals in Latin America.

BACKGROUND: Antimicrobial resistance has worsened in Latin America. There is an urgent need to understand the development of antimicrobial stewardship programs (ASPs) and the barriers to implementing effective ASPs in light of limited national action plans or policies to promote ASPs in the region. METHODS: We performed a descriptive mixed-methods study of ASPs in 5 Latin American countries in March-July 2022. An electronic questionnaire with an associated scoring system (hospital ASP self-assessment) was used, and ASP development was classified based on the scores (inadequate, 0-25; basic, 26-50; intermediate, 51-75; or advanced, 76-100). Interviews among healthcare workers (HCWs) involved in antimicrobial stewardship (AS) inquired about behavioral and organizational factors that influence AS activities. Interview data were coded into themes. Results from the ASP self-assessment and interviews were integrated to create an explanatory framework. RESULTS: Twenty hospitals completed the self-assessment, and 46 AS stakeholders from these hospitals were interviewed. ASP development was inadequate/basic in 35% of hospitals, intermediate in 50%, and advanced in 15%. For-profit hospitals had higher scores than not-for-profit hospitals. Interview data validated the self-assessment findings and provided further insight into ASP implementation challenges, which included limited formal hospital leadership support, inadequate staffing and tools to perform AS work more efficiently, limited awareness of AS principles by HCWs, and limited training opportunities. CONCLUSIONS: We identified several barriers to ASP development in Latin America, suggesting the need to create accurate business cases for ASPs to obtain the necessary funding for their effective implementation and sustainability.

[Multicenter study of COVID-19 incidence and determinants in Argentinian physicians]. / Estudio multicéntrico de incidencia y determinantes de COVID-19 en médicos de Argentina.

BACKGROUND: Information about COVID infection in physicians is limited. This knowledge would allow the implementation of actions to reduce its impact. The objective was determining the incidence of SARSCoV-2 infection in physicians from health institutions in Argentina, its characteristics, and associated factors. METHODS: We conducted a multicenter prospective / retrospective cohort study with nested case-control study. Physicians active at the beginning of the pandemic were included, those on leave due to risk factors were excluded. The incidence of confirmed cases was estimated. We conducted bivariate analyses with various factors and used those significant in a logistic regression. RESULTS: Three hundred and forty three physicians with COVID-infection from 8 centers were included. The incidence of disease was 12.1% and that of global absenteeism related to COVID, 34.1%. Almost 70% of close contacts were work-related. In the multivariate analysis living in Autonomous City of Buenos Aires (CABA) (OR 0.19, p = 0.01), working in high-risk areas (OR 0.22, p = 0.01) and individual transportation (OR 0, 34, p = 0.03) reduced the risk of COVID. The odds of infection increased 5.6 times (p = 0.02) for each close contact isolation. DISCUSSION: The number of close contact isolation increased considerably the risk of infection. Living in Buenos Aires City, individual transportation and working in high-risk areas reduced it. Given the high frequency of close contact in the workplace, we strongly recommend the reinforcement of prevention measures in rest areas and non-COVID-wards.

Introducción: La información sobre COVID en médicos es limitada. Su conocimiento permitiría implementar acciones para reducir su impacto. El objetivo general fue determinar la incidencia de infección por SARS-CoV-2 en médicos de instituciones de salud de Argentina, sus características y factores asociados. Materiales y Métodos: Se realizó un estudio multicéntrico de cohorte prospectiva/retrospectiva con estudio de casos-controles anidado. Se incluyeron médicos activos al inicio de la pandemia no exceptuados por riesgo. Se estimó incidencia de casos confirmados. Se compararon factores asociados en casos y controles y se creó un modelo de regresión logística con las variables significativas del análisis bivariado. Resultados: Se incluyeron 343 médicos con COVID de 8 centros. La incidencia de la enfermedad fue de 12.1% y la de ausentismo global relacionado a COVID, de 34.1%. El 70% de los contactos estrechos fueron laborales. En el análisis multivariado de casos y controles, la residencia en la Ciudad Autónoma de Buenos Aires (OR 0.19, p = 0.01), el trabajo en áreas de alto riesgo (OR 0.22, p = 0.01) y vehículo individual (OR 0.34, p = 0.03) redujeron el riesgo de COVID. El odds de enfermar aumentó 4.6 veces (p = 0.02) por cada aislamiento por contacto estrecho. Discusión: El riesgo de enfermar aumentó considerablemente con cada aislamiento por contacto estrecho. La residencia en Ciudad Autónoma, el traslado en vehículo individual y el trabajo en áreas de alto riesgo lo redujeron. Dada la alta frecuencia de contactos estrechos en el ámbito laboral recomendamos reforzar las medidas de prevención en áreas de descanso y no COVID.

Estudio multicéntrico de incidencia y determinantes de COVID-19 en médicos de Argentina / Multicenter study of COVID-19 incidence and determinants in Argentinian physicians

Resumen Introducción: La información sobre COVID en médicos es limitada. Su conocimiento permitiría implementar acciones para reducir su impacto. El objetivo general fue determinar la incidencia de infección por SARS-CoV-2 en médicos de instituciones de salud de Argentina, sus características y factores aso ciados. Materiales y Métodos: Se realizó un estudio multicéntrico de cohorte prospectiva/retrospectiva con estudio de casos-controles anidado. Se incluyeron médicos activos al inicio de la pandemia no exceptuados por riesgo. Se estimó incidencia de casos confirmados. Se compararon factores asociados en casos y controles y se creó un modelo de regresión logística con las variables significativas del análisis bivariado. Resultados: Se incluyeron 343 médicos con COVID de 8 centros. La incidencia de la enfermedad fue de 12.1% y la de ausentismo global relacionado a COVID, de 34.1%. El 70% de los contactos estrechos fueron laborales. En el análisis multivariado de casos y controles, la residencia en la Ciudad Autónoma de Buenos Aires (OR 0.19, p = 0.01), el trabajo en áreas de alto riesgo (OR 0.22, p = 0.01) y vehículo individual (OR 0.34, p = 0.03) redujeron el riesgo de COVID. El odds de enfermar aumentó 4.6 veces (p = 0.02) por cada aislamiento por contacto estrecho. Discusión: El riesgo de enfermar aumentó considerablemente con cada aislamiento por contacto estrecho. La residencia en Ciudad Autónoma, el traslado en vehículo individual y el trabajo en áreas de alto riesgo lo redujeron. Dada la alta frecuencia de contactos estrechos en el ámbito laboral recomendamos reforzar las medidas de prevención en áreas de descanso y no COVID.

Abstract Background: Information about COVID infection in physicians is limited. This knowledge would allow the implementation of actions to reduce its impact. The objective was determining the incidence of SARS-CoV-2 infection in physicians from health institutions in Argentina, its characteristics, and associated factors. Methods: We conducted a multicenter prospective / retrospective cohort study with nested case-control study. Physicians active at the beginning of the pandemic were included, those on leave due to risk factors were excluded. The incidence of confirmed cases was estimated. We conducted bivariate analyses with various factors and used those significant in a logistic regression. Results: Three hundred and forty three physicians with COVID-infection from 8 centers were included. The incidence of disease was 12.1% and that of global absenteeism related to COVID, 34.1%. Almost 70% of close contacts were work-related. In the multivariate analysis living in Autonomous City of Buenos Aires (CABA) (OR 0.19, p = 0.01), working in high-risk areas (OR 0.22, p = 0.01) and individual transportation (OR 0, 34, p = 0.03) reduced the risk of COVID. The odds of infection increased 5.6 times (p = 0.02) for each close contact isolation. Discussion: The number of close contact isolation increased considerably the risk of infection. Living in Buenos Aires City, individual transpor tation and working in high-risk areas reduced it. Given the high frequency of close contact in the workplace, we strongly recommend the reinforcement of prevention measures in rest areas and non-COVID-wards.

Ivermectin to prevent hospitalizations in patients with COVID-19 (IVERCOR-COVID19) a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) has changed our lives. The scientific community has been investigating re-purposed treatments to prevent disease progression in coronavirus disease (COVID-19) patients. OBJECTIVE: To determine whether ivermectin treatment can prevent hospitalization in individuals with early COVID-19. DESIGN, SETTING AND PARTICIPANTS: A randomized, double-blind, placebo-controlled study was conducted in non-hospitalized individuals with COVID-19 in Corrientes, Argentina. Patients with SARS-CoV-2 positive nasal swabs were contacted within 48 h by telephone to invite them to participate. The trial randomized 501 patients between August 19th 2020 and February 22nd 2021. INTERVENTION: Patients were randomized to ivermectin (N = 250) or placebo (N = 251) arms in a staggered dose, according to the patient's weight, for 2 days. MAIN OUTCOMES AND MEASURES: The efficacy of ivermectin to prevent hospitalizations was evaluated as primary outcome. We evaluated secondary outcomes in relationship to safety and other efficacy end points. RESULTS: The mean age was 42 years (SD ± 15.5) and the median time since symptom onset to the inclusion was 4 days [interquartile range 3-6]. The primary outcome of hospitalization was met in 14/250 (5.6%) individuals in ivermectin group and 21/251 (8.4%) in placebo group (odds ratio 0.65; 95% confidence interval, 0.32-1.31; p = 0.227). Time to hospitalization was not statistically different between groups. The mean time from study enrollment to invasive mechanical ventilatory support (MVS) was 5.25 days (SD ± 1.71) in ivermectin group and 10 days (SD ± 2) in placebo group, (p = 0.019). There were no statistically significant differences in the other secondary outcomes including polymerase chain reaction test negativity and safety outcomes. LIMITATIONS: Low percentage of hospitalization events, dose of ivermectin and not including only high-risk population. CONCLUSION: Ivermectin had no significant effect on preventing hospitalization of patients with COVID-19. Patients who received ivermectin required invasive MVS earlier in their treatment. No significant differences were observed in any of the other secondary outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04529525 .

Ivermectin to prevent hospitalizations in patients with COVID-19 (IVERCOR-COVID19): a structured summary of a study protocol for a randomized controlled trial.

OBJECTIVES: To assess the efficacy of ivermectin in addition to standard treatment compared to standard treatment alone in reducing hospitalizations in the COVID-19 patient population. TRIAL DESIGN: IVERCOR-COVID19 will be a single-center, prospective, randomized, double-blind, parallel group (1:1 ratio), placebo-controlled study. PARTICIPANTS: Patients who meet the following criteria will be invited to participate: Inclusion criteria: (1) Over 18 years of age who reside in the province of Corrientes at the time of diagnosis. (2) Confirmed diagnosis of COVID-19 by polymerase chain reaction (PCR) test for detection of SARS-CoV2 in the last 48 h. (3) In the case of women of childbearing age, they must be using a contraceptive method of proven efficacy and safety (barrier, hormonal, or permanent contraceptives) for at least 3 months prior to inclusion in the present study and for the entire period of time for the duration of the study and until at least 30 days after the end of this study. A woman will be considered to have no reproductive capacity if she is postmenopausal (at least 2 years without her menstrual cycles) or if she has undergone surgical sterilization (at least 1 month before the time of inviting her to participate in this study). (4) Weight at the time of inclusion greater than 48 kg. (5) That they sign the informed consent for participation in the study. EXCLUSION CRITERIA: (1) pregnant or breastfeeding women; (2) known allergy to ivermectin or some of the components of ivermectin tablets or placebo; (3) current use of home oxygen; (4) require hospitalization due to COVID-19 at the time of diagnosis or history of hospitalization for COVID-19; (5) presence of mal-absorptive syndrome; (6) presence of any other concomitant acute infectious disease; (7) known history of severe liver disease, for example liver cirrhosis; (8) need or use of antiviral drugs at the time of admission for another viral pathology other than COVID-19; (9) need or use of hydroxychloroquine or chloroquine; (10) use of ivermectin up to 7 days prior to randomization; (11) patients on dialysis or who have required it in the last 2 months or who plan to do it in the next 2 months; and (12) current participation or in the last 30 days in a research study that has included the administration of a drug (Table 1). Table 1 Ivermectin/placebo dose according to patient weight Patient weight Ivermectin/placebo dose Total dose (mg) Equal to or greater than 48 kg and less than 80 kg 2 tablets of 6 mg each at the time of inclusion and 2 tablets 24 h after the first intake 24 Equal or greater than 80 kg and less than 110 kg 3 tablets of 6 mg each at the time of inclusion and 3 tablets 24 h after the first intake 36 Equal or greater than 110 kg 4 tablets of 6 mg each at the time of inclusion and 4 tablets 24 h after the first intake 48 The study will be carried out by the Ministry of Public Health of the Province of Corrientes (Argentina) in coordination with the Institute of Cardiology of Corrientes in the Province of Corrientes, Argentina. INTERVENTION AND COMPARATOR: Intervention group: patients who are randomized to ivermectin will receive the dose according to their weight (patients up to 80 kg will receive 2 tablets of 6 mg ivermectin; patients with more than 80 kg and up to 110 kg will receive 3 tablets of 6 mg of ivermectin; patients weighing more than 110 kg will receive 4 tablets of 6 mg ivermectin) the day they enter the study and the same dose 24 h after the first dose. CONTROL GROUP: patients who are randomized to placebo will receive the dose according to their weight (patients up to 80 kg will receive 2 tablets of 6 mg placebo; patients with more than 80 kg and up to 110 kg will receive 3 tablets of 6 mg of placebo; patients weighing more than 110 kg will receive 4 tablets of 6 mg placebo) on the day they enter the study and the same dose 24 h after the first dose (Table 2). Table 2 Inclusion and exclusion criteria Inclusion criteria Exclusion criteria 1. Over 18 years of age who reside in the province of Corrientes at the time of diagnosis 1. Pregnant or breastfeeding women 2.Confirmed diagnosis of COVID-19 by polymerase chain reaction test for detection of SARS-CoV2 in the last 48 h 2. Known allergy to ivermectin or some of the components of ivermectin tablets or placebo 3. In case of being women of childbearing age, they must be using a contraceptive method of proven efficacy and safety (barrier, hormonal, or permanent contraceptives) for at least 3 months prior to inclusion in the present study, during the entire period of time for the duration of the study, and until at least 30 days after the end of this study. A woman will be considered to have no reproductive capacity if she is postmenopausal (at least 2 years without her menstrual cycles) or if she has undergone surgical sterilization (at least 1 month before the time of inviting her to participate in this study) 3. Current use of home oxygen 4. Weight at the time of inclusion equal to or greater than 48 kg 4. That require hospitalization due to COVID-19 at the time of diagnosis or history of hospitalization for COVID-19 5. That they sign the informed consent for participation in the study 5. Presence of mal-absorptive syndrome 6. Presence of any other concomitant acute infectious disease 7. Known history of severe liver disease, for example liver cirrhosis 8. Need or use of antiviral drugs at the time of admission for another viral pathology other than COVID-19 9. Need or use of hydroxychloroquine or chloroquine 10. Use of ivermectin up to 7 days prior to randomization 11. Patients on dialysis or who have required it in the last 2 months or who plan to do it in the next 2 months 12. Current participation or in the last 30 days in a research study that has included the administration of a drug MAIN OUTCOMES: Primary outcome will be the percentage of hospitalizations in patients with COVID-19 in the intervention and control groups. SECONDARY OUTCOMES: time to hospitalization in each of the arms of the study: number of days elapsed from the inclusion in the study until the hospitalization of the patient; percentage of use of invasive mechanical ventilation in each of the study arms: every patient who is connected to invasive mechanical ventilation after signing the informed consent and before the final study visit; time to invasive mechanical ventilation in each of the arms of the study: number of days elapsed from inclusion in the study to connection to invasive mechanical ventilation of the patient; percentage of patients requiring dialysis in each of the study arms: all patients who require renal replacement therapy of any kind, temporary or permanent, and which begins after signing the informed consent and before the final visit; mortality from all causes in each of the two trial groups: death of the patient, from any cause. Negative PCR swab at 3 ± 1 and 12 ± 2 days after entering the study. Ivermectin safety: it will be analyzed according to the incidence of adverse events that patients present in the intervention and control groups. The end of study (EOS) is recorded as the day the patient is discharged or death. Discharge will be granted according to the current recommendations of the Ministry of Public Health of the Province of Corrientes. A follow-up visit (EOF) will be made by phone 30 days after the EOS when vital status will be verified. RANDOMIZATION: Randomization will be done through a web system with randomly permuted blocks. Randomization will be carried out by one of the investigators who will not participate in the inclusion of patients or in the delivery of medication (Table 3). Table 3 EOS end of study, EOF end of follow-up Visit Basal and randomization, day 0 Day 3 ± 1 Day 12 ± 2 V#1 V#2 V#3 EOS EOF Informed consent X - - - - Inclusion/exclusion criteria X - - - - Demographic data and medical history X - - - - Concomitant medication X - - - - Vital signs* X X - - - Anthropometric data^ X - - - - Basal laboratory X - - - - PCR swab - X X - - Assessment of adverse events - X X X - Final objective evaluation - X X X X Randomization X - - - - Adherence to treatment X X - - - *Includes heart rate, temperature, and oxygen saturation by a digital saturometer ^Includes weight and height BLINDING (MASKING): The participants, investigators, care providers, and outcome assessors will be blinded. NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): We will include a total of 500 patients (250 patients in each group). TRIAL STATUS: This is version 1.0, 17 August 2020. The recruitment started on 19 August 2020, and we anticipate the trial will finish recruitment on 31 December 2020. TRIAL REGISTRATION: ClinicalTrials.gov NCT04529525 . Registered on 26 August 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting the dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.

[Intersociety guidelines for diagnosis, treatment and prevention of Clostridioides difficile infections]. / Recomendaciones intersociedades para diagnóstico, tratamiento y prevención de las infecciones por Clostridioides difficile.

Clostridioides difficile infections (CDI) are among the leading causes of health care-associated infections. The epidemiology of CDI has undergone major changes in the last decade, showing an increase in incidence, severity, and rate of relapse. These guidelines were developed by specialists from four scientific societies: Sociedad Argentina de Infectología (SADI), Sociedad Argentina de Gastroenterología (SAGE), Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas (SADEBAC) and Asociación de Enfermeras en Control de Infecciones (ADECI). The objective of these intersociety guidelines is to provide national recommendations on CDI diagnosis, treatment and prevention. The methodology used involved the systematic review of the bibliography available up to December 2018, which was performed by six groups formed ad hoc: Epidemiology, Diagnosis, Treatment, Fecal Microbiota Transplantation, Special Populations, and Infection Control. The conclusions were presented and discussed in meetings held by each individual group and plenary meetings. In this document, updated diagnosis algorithms, therapeutic options (including fecal microbiota transplant) for immunocompetent and immunocompromised patients are presented, as well as strategies for the control of C. difficile infection.

Las infecciones por Clostridioides difficile están entre las principales causas de infecciones asociadas al sistema de salud. Su epidemiología ha sufrido importantes cambios en la última década con aumento en incidencia, gravedad y frecuencia de recidivas. El objetivo de este documento es brindar recomendaciones nacionales para el diagnóstico, el tratamiento y la prevención de las infecciones por C. difficile. Estas recomendaciones fueron elaboradas por especialistas pertenecientes a cuatro sociedades científicas de la República Argentina: Sociedad Argentina de Infectología (SADI), Sociedad Argentina de Gastroenterología (SAGE), Sociedad Argentina de Bacteriología, Micología y Parasitología Clínica (SADEBAC) y Asociación de Enfermeros en Control de Infecciones (ADECI). La metodología utilizada consistió en la revisión sistemática de la evidencia publicada hasta diciembre 2018. Seis grupos de especialistas fueron formados a tal fin: Epidemiología, Diagnóstico, Tratamiento, Trasplante de Microbiota Fecal, Poblaciones Especiales y Control de Infecciones. En reuniones individuales de grupo y plenarias se presentaron y discutieron las conclusiones y se elaboraron las recomendaciones. En este documento se actualizan los algoritmos diagnósticos, las opciones terapéuticas, incluido el trasplante de microbiota fecal, en paciente inmunocompetentes e inmunocomprometidos, y las medidas de control de infecciones por C. difficile.

Relación entre desarrollo de los programas para la gestión del uso de antimicrobianos, apropiabilidad y consumo de antibióticos en hospitales de Argentina / Relationship between the antimicrobial stewardship program development, appropriateness and antimicrobial consumption in Argentinean hospitals

Introducción: La implementación de Programas para la Optimización de Uso de Antimicrobianos (PROAs) ha resultado una estrategia útil para mejorar los resultados asistenciales, de manera segura y costo-efectiva, reduciendo el desarrollo de la resistencia a los antimicrobianos.Objetivo: Estimar la relación entre nivel de desarrollo de los PROAs, apropia-bilidad y consumo de antimicrobianos en hospitales ArgentinosMaterial y métodos: Entre Jul-2016 y Ene-2017, 111 hospitales condujeron una autoevaluación del nivel de desarrollo de sus PROAs usando un instrumen-to basado en los lineamientos del CDC (0 a 100 puntos), además de un cor-te de prevalencia para evaluar la apropiabilidad de las prescripciones de an-timicrobianos y su consumo mensual [Dosis Diarias Definidas (DDD) c/100 días-paciente]. Para la comparación de estos indicadores, los centros fueron dicotomizados tomando como punto de corte el percentilo 75 (p75) de la au-toevaluación.Resultados: La comparación entre hospitales con puntaje ≥p75 vs.

Objective: To assess the association between the level of AMS programs development, appropriateness and antimicrobial consumption in Argentinean hospitalsMaterial and methods: Between Jul-2016 and Jan-2017, 111 hospitals performed a self-assessment survey of their AMS programs using a standardized tool based on CDC recommendations (0­100 scale). In addition, the appropriateness of antimicrobial prescription was measured through one-day prevalence study using specific criteria. The monthly consumption of a group of antimicrobials was calculated using Defined Daily Doses (DDD) per 100 patient-days. To assess the relationship between the level of AMS programs development and the appropriateness and antimicrobial consumption indicators, participating centers were grouped into two categories by using the 75th percentile (75thp) of the self-assessment scoreResults: Comparison between hospitals with score ≥75thp vs <75thp showed significant differences in all indicators analyzed (self-assessment score: 51.6 vs 25.4; diff. 26.2; 95%CI 30.3 to 22.0, p<0.000; surgical prophylaxis: ≤ 24 hs 64.8% vs 52.3%; diff. 12.5%; 95%CI 5.1% to 20.0%, p<0.002; compliance with guidelines: 77.6% vs 47.0%; diff. 30.6%; 95%CI 28.1% to 33.0%, p<0.000; prospective audit with feedback: 69.4% vs 46.8%; diff. 22.6%; 95%CI 20.0% to 25.2%, p<0.000; antimicrobial consumption: 114.8 DDDs vs 259.2 DDDs; diff.­144.4; 95%CI ­140.6 to ­148.2, p<0.000)Conclusions: Hospitals with higher self-assessment score showed better appropriateness and consumption antimicrobial indicators, reinforcing the relevance of an effective implementation of AMS programs

Benznidazole and Posaconazole in Eliminating Parasites in Asymptomatic T. Cruzi Carriers: The STOP-CHAGAS Trial.

BACKGROUND: Benznidazole is recommended for treatment of Chagas infection. Effects of combination therapy with benznidazole and posaconazole have not been tested in Trypanosoma cruzi carriers. OBJECTIVES: The purpose of this study was to determine whether posaconazole alone or combined with benznidazole were superior to benznidazole monotherapy in eliminating T. cruzi parasites measured by real time polymerase chain reaction (RT-PCR) in asymptomatic Chagas carriers. METHODS: A prospective, multicenter randomized placebo-controlled study was conducted in 120 subjects from Latin America and Spain who were randomized to 4 groups: posaconazole 400 mg twice a day (b.i.d.); benznidazole 200 mg + placebo b.i.d.; benznidazole 200 mg b.i.d. + posaconazole 400 mg b.i.d.; or placebo 10 mg b.i.d. T. cruzi deoxyribonucleic acid was detected by RT-PCR at 30, 60, 90, 120, 150, 180, and 360 days. The primary efficacy outcome is the proportion of subjects with persistent negative RT-PCR by day 180; the secondary outcome was negative RT-PCR at 360 days. RESULTS: Only 13.3% of those receiving posaconazole and 10% receiving placebo achieved the primary outcome, compared with 80% receiving benznidazole + posaconazole and 86.7% receiving benznidazole monotherapy (p < 0.0001 vs. posaconazole/placebo). Posaconazole monotherapy or posaconazole combined with benznidazole achieved high RT-PCR conversion rates during treatment (30 days; 93.3% and 88.9% and 60 days; 90%, and 92.3%) that were similar to benznidazole (89.7% and 89.3%); all were superior to placebo or posaconazole (10% and 16.7%, p < 0.0001). This was not observed at 360 days; benznidazole + posaconazole and benznidazole monotherapy (both 96%) versus placebo (17%) and posaconazole (16%, p < 0.0001). Serious adverse events were rare (6 patients) and were observed in the benznidazole-treated patients. Permanent discontinuation was reported in 19 patients (31.7%) receiving either benznidazole monotherapy or combined with posaconazole. CONCLUSIONS: Posaconazole demonstrated trypanostatic activity during treatment, but it is ineffective long-term in asymptomatic T. cruzi carriers. Benznidazole monotherapy is superior to posaconazole, with high RT-PCR conversion rates sustained at 1 year. Side effects lead to therapy discontinuation in 32%. No advantages were observed with combined therapy versus benznidazole monotherapy. (A Study of the Use of Oral Posaconazole [POS] in the Treatment of Asymptomatic Chronic Chagas Disease [P05267] [STOP CHAGAS]: NCT01377480).

Infección urinaria por enterobacterias multirresistentes en un centro de trasplante renal / Urinary Tract Infection by Multiresistant Enterobacteriaceae in a Renal Transplant Center

La infección bacteriana del tracto urinario (ITU) es la cau-sa más frecuente de complicación en el paciente trasplantado renal. Nuestros objetivos fueron determinar los patógenos mas frecuentes, su asociación al tiempo transcurrido al primer episodio de ITU, los factores de riesgo predisponentes y la sensibilidad antibiótica de los gérmenes.Materiales y Métodos: se realizó un estudio retrospectivo en el que se siguió por un año a los pacientes trasplantados renales entre noviem-bre de 2006 a febrero de 2012. Se incluyó el primer urocultivo positivo con bacilos gram negativos. Resultados: de 156 pacientes analizados, 63 (40 %) tuvieron al menos un episodio de ITU en el que se caracterizaron los microorganismos responsables. El patógeno más frecuente fue Klebsiella pneumoniae(25/63 episodios, 39 %), seguido por Escherichia coli (23/63, 37 %). Casi la mitad (31/63, 49 %) ocurrieron antes de los 30 días (58 % por K. pneu-moniae), un tercio (18/63, 29 %) entre los 31 y 180 días (39 % por E. coli) y el resto (14/63, 22 %) en el medio año siguiente (64 % de ellas cau-sadas por E. coli). Entre las K. pneumoniae, 22/25 (88 %) resultaron productoras de ß lactamasas de espectro extendido. Como factores de riesgo predisponentes se encontraron sexo femenino, litiasis renal previa y utilización de catéter doble J. Conclusión: este estudio confirma que las ITU son una complicación frecuente en los transplantados renales. La asociación de K. pneumo-niae multirresistentes con las infecciones inmediatas puede ser consi-derada como marcadora de infección intrahospitala-ria, y señala la posibilidad de realizar intervenciones que modifiquen su incidencia

Urinary tract infections (UTI) are the most frequent complication in renal transplant patients. Our aims were to determine the most common pathogens, the association of different enterobacterias with the time of the onset of the infection, the impact of several risk factors and antibiotic susceptibility.Materials and Methods: The patients were monitored for a year after the renal transplant from November 2006 to February 2012. A retrospective analysis was done and the first positive urine culture with gram negative bacilli was included.Results: From a total of 156 patients analyzed, 63 (40%) had at least one experience of UTI in which the responsible microorganisms were characterized. The most common pathogen was Klebsiella pneumoniae (25/63 episodes, 39 %), followed by Escherichia coli (23/63, 37 %). Almost half of the cases (31/63, 49%) occurred within 30 days (58% for K. pneumoniae), one third of them (18/63, 29%) between 31 and 180 days (39% for E. coli) and the remainings (14/ 63, 22%) in the next half year (64% of them caused by E. coli). Most of the K. pneumoniae, (22/25, 88%) were extended spectrum ß lactamases producers. We can mention as predisposing risk factors: female gender, lithiasis and urinary stent presence. Conclusion: This study confirms that UTIs are a frequent complication in renal transplantation. The association of multiresistant K. pneumoniae infections with immediate UTI can be considered as a marker of nosocomial infection, and points out intervention as a possibility to modify this impact

Pandemic influenza A/H1N1 virus infection in solid organ transplant recipients: a multicenter study.

BACKGROUND: The 2009 novel influenza A/H1N1 virus pandemic did not spare solid organ transplant (SOT) recipients. We aimed to describe the behavior of pandemic influenza infection in a group of SOT recipients in Argentina. METHODS: Data from 10 transplant (Tx) centers were retrospectively collected for SOT that presented with a respiratory illness compatible with pandemic influenza A infection, between May and September 2009. Cases were defined as suspected, probable, or confirmed according to diagnostic method. RESULTS: Seventy-seven cases were included. No significant differences in presenting symptoms, pulmonary infiltrates, and graft involvement were found among 35 suspected, 19 probable, and 23 confirmed cases. The 33 ambulatory cases had significantly more sore throat and headache when compared with 34 cases admitted to medical ward (MW) and 10 admitted to intensive care unit (ICU), 9 of whom required ventilatory support. MW and ICU cases had significantly more dyspnea, hypoxemia, pulmonary infiltrates, and graft dysfunction. Time from onset of symptoms to first visit and to treatment was significantly longer in MW and ICU cases (P=0.008). Coinfections were found in six cases. Most cases received oseltamivir for 5 to 10 days. Six patients (7.8%) died from viral infection at a median of 15 days from admission. No differences in outcome were seen related to the transplanted organ, the immunosuppressive regimen, time from Tx, or confirmation of diagnosis. CONCLUSIONS: Mortality is higher in Tx recipients than in the general population. Poor outcome seems to be related to a delay in the beginning of treatment.

Infecciones asociadas a stent coronario: presentación de un caso y definición / Coronary stent infection: Case report and definition

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