Vascular catheter-related infections: an endemic disease in healthcare institutions. An opinion paper of the Spanish Society of Cardiovascular Infections (SEICAV).

Catheter-related infections (CRI) are a serious healthcare problem due to their potential to cause serious complications, including bacteraemia or infective endocarditis, and to increase patient morbidity and mortality. In addition, these in fections significantly prolong hospital stay and cost. Preventing CRI is crucial and is considered a criterion for quality and safety in healthcare. For these reasons, the Spanish Society of Cardiovascular Infections (SEICAV) has considered it pertinent to review this topic, with experts in different areas including clinical microbiologists, infectious disease specialists, surgeons and nurses. The data were presented at a session held at the Ramón Areces Foundation, which was organised in the form of specific questions grouped into three round tables. The first panel analysed the scale of the problem including epidemiological, clinical and diagnostic aspects; the second panel addressed advances in the treatment of CRI; and the third panel reviewed developments in the prevention of CRI. The recorded session is available on the Areces Foundation website and we believe it maybe of interest not only to health professionals, but also to any non-expert citizen interested in the subject.

Cytomegalovirus reactivation in patients diagnosed with severe COVID-19: A point prevalence study in a general hospital.

OBJECTIVE: To determine the prevalence of CMV reactivation in a population admitted for severe COVID-19 to a general hospital. METHODS: Point prevalence study in all hospitalized patients with severe COVID-19 (admitted either to general wards or ICU). Determination of the presence of CMV DNA in circulating blood. COVID-19 was confirmed in patients with compatible clinical manifestations, usually with pneumonia and a positive nasopharyngeal PCR test. RESULTS: We included 140 hospitalized patients with COVID-19 who consented to participate. A total of 16 patients (11.42%), had circulating CMV-DNA in peripheral blood at the time of the study. Patients with positive CMV viral load were mainly ICU patients (11/37 -29,7%) and only 5/103 cases (4,85%) were hospitalized into general wards. The accumulated doses of corticosteroids (prednisone equivalents) in the study day were (median and IQR) 987.50 mg (396.87-2,454.68) and 187.50 mg (75.00-818.12) respectively in CMV positive and negative patients (p < 0.001). A significant proportion of CMV positive patients were discovered because of the study and were clinically unsuspected by their physicians. The coinfected COVID-CMV positive population had a higher risk of accumulated secondary nosocomially-acquired infections and a worse prognosis. CONCLUSIONS: CMV reactivation should be systematically searched in patients in COVID-19 cases admitted to the ICU.

High incidence of COVID-19 at nursing homes in Madrid, Spain, despite preventive measures.

OBJECTIVE: To assess the impact of COVID-19 at nine nursing homes in Madrid, Spain, during the first wave of COVID-19 infection and lockdown period when preventive measures were taken to avoid transmission among residents. METHODS: Nine hundred forty-two residents and 846 staff members from nine nursing homes participated in the study (April 18 to June 20, 2020). All participants were tested for SARS-CoV-2 in the nasopharynx by PCR and for IgG antibodies detection. Microbiological status at sampling was defined as active infection (positive PCR ± presence of antibodies), past infection (negative PCR + presence of antibodies), or naïve participants (negative PCR + absence of antibodies). RESULTS: Laboratory results helped classify the residents as having active infection (n=224; 23.8%), past infection (n=462; 49.1%), or being naïve (n=256; 27.1%); staff members were actively infected (n=127; 15.1%), had had a past infection (n=290; 34.2%), or were naïve (n=429; 50.7%). Overall, the percentage of participants with COVID-19 was significantly higher in residents than in staff members (72.8% vs 49.2%; P=0.001). The clinical situation of residents vs staff at sampling was as follows: acute manifestations compatible with COVID-19 (7.3% vs 3.9%; P<0.01) and no manifestations of infection (92.7% vs 96.0%; P<0.01). A large proportion of both asymptomatic and symptomatic residents (69.4% vs 86.6%; P=0.015) had positive PCR results (mostly alongside positive IgG determinations). CONCLUSIONS: COVID-19 affects 75% of the residents in nursing homes in Madrid. The high impact in these settings, despite the strict restrictions adopted during the lockdown, demonstrates the ability of SARS-CoV-2 to cause outbreaks.

Increase in the frequency of catheter-related bloodstream infections during the COVID-19 pandemic: a plea for control.

BACKGROUND: The incidence of nosocomial infections including ventilator-associated pneumonia and bacteraemia has been described during the COVID-19 pandemic. However, information regarding the impact of COVID-19 on the incidence of catheter-related bloodstream infections (CR-BSIs) is very limited. AIM: To evaluate the impact of the COVID-19 pandemic in the evolution of CR-BSIs in a large hospital. METHODS: This was a retrospective study comparing the incidence, aetiology and outcome of CR-BSIs during the months of March to May 2019 (pre-pandemic) and 2020 (during the pandemic). FINDINGS: The number of patients with one or more CR-BSIs in 2019 and 2020 were 23 and 58, respectively (1.89 vs 5.53/1000 admissions); P<0.001. Median time from catheter implantation to demonstration of CR-BSI was 27.5 days (range 11.75-126.00 days) in the 2019 cases and 16.0 days (range 11.00-23.50 days) in the 2020 population (P=0.032). CONCLUSIONS: A dramatic increase of CR-BSIs was found during the COVID-19 pandemic. Reinforcement of classic and new preventive measures is necessary.

Inmunoterapia oral con huevo en un hospital comarcal / Oral immunotherapy with egg in a regional hospital

Introducción y objetivos. La inmunoterapia oral (ITO) es una alternativa a la dieta de evitación en algunas alergias alimentarias. El objetivo de este trabajo es evaluar la eficacia y seguridad de la ITO con huevo en una consulta de alergia pediátrica. Material y métodos. Estudio observacional, longitudinal y retrospectivo de pacientes pediátricos con alergia al huevo persistente sometidos a ITO. Para la inducción se utilizó proteína de clara de huevo deshidratada administrada diariamente y con incrementos semanales hasta alcanzar una dosis de 4 gramos. Para la fase de mantenimiento se indicó una ingesta de al menos dos o tres huevos a la semana. Resultados. Se trataron 14 pacientes (6 niñas), de entre 5 y 13 años (mediana 5,5 años). Se consiguió desensibilización completa al final de la inducción en 11 pacientes (78,6%), que se mantuvo en todos ellos tras una mediana de tiempo de seguimiento de 29 meses. Durante la inducción los síntomas más frecuentes fueron: prurito orofaríngeo (9/14), dolor abdominal (7/14) y rinoconjuntivitis (6/14). Se emplearon antihistamínicos en 8 casos (57,1%) y ninguno precisó adrenalina. Entre los pacientes que consiguieron desensibilización se observó una tendencia al descenso de las IgE específicas, siendo estadísticamente significativo para las IgE a huevo completo (p = 0,047), clara de huevo (p = 0,031) y ovoalbúmina (p = 0,016). Conclusiones. La ITO con clara de huevo deshidratada resultó ser un tratamiento muy eficaz y bien tolerado en población pediátrica con alergia al huevo (AU)

Background and objective. Oral immunotherapy (OIT) is an alternative to strict avoidance for the management of some food allergies. The aim of this study is to assess the efficacy and safety of egg OIT in a paediatric allergy outpatient service. Methods. Retrospective, longitudinal observational study in children with persistent hen egg allergy who received egg OIT. For the build-up phase, dehydrated egg white was used daily. Updosing was performed weekly at the allergy unit, up to a final dose of 4 grams. Maintenance phase was carried out with a daily intake of one egg at least two or three times a week. Results. 14 patients (6 girls), whose ages ranged from 5 to 13 years (median 5.5 years) were treated with egg OIT. Eleven subject (78.6%) reached total desensitization, and all of them remained desensitized after a median follow-up time of 29 months. The most frequent adverse effects detected during the build-up phase were: oropharyngeal pruritus (9/14), abdominal pain (7/14), and rhinoconjuntivitis (6/14). Eight patients (57.1%) required oral antihistamines, and none received adrenaline. In those subjects that reached total desensitization, a trend to lower specific IgE levels was observed. That trends were statistically significand for whole egg (p = 0.047), egg white (p = 0.031), and ovalbumin (p = 0.016). Conclusions. Egg OIT was an effective and well tolerated treatment in children with egg allergY (AU)

Motiva.DM2 project. A pilot behavioral intervention on diet and exercise for individuals with type 2 diabetes mellitus.

AIM: The purpose of this study was to assess the efficacy of an educational intervention based on the Behavior Change Wheel (BCW) framework for individuals with type 2 diabetes mellitus (DM2) on dietary and exercise behavior in a Spanish region. METHODS: A two-arm pilot research was developed. The intervention consisted of a 6-month period with guidelines and 4 in-person interventions. The outcome was changes in behaviors, motivation, competence, autonomy, social support to implement the recommendations, HbA1c, and body composition. RESULTS: n = 111 patients were recruited. Individuals in the intervention experienced a significative improvement on adherence to dietary recommendations (+1.23; p = 0.026), exercise (+0.86; p = 0.001), and a decrease in HbA1c levels (-0.6%; p = 0.002) and BMI (-0.73; p < 0.001). CONCLUSION: The intervention for DM2 individuals, based on the BCW framework, developed, and implemented by primary care nurses has been effective in improving the adherence to healthy eating, exercise, HbA1c levels, and body composition.

Medical education from the point of view of medical students: Results from four participatory Delphi panels in Quito, Ecuador.

BACKGROUND: Medical curricula have historically been designed in a top-down approach, usually excluding students. While Delphi panels have been used as a tool for medical education curricula design, none have been conducted in Ecuador. In addition, no such approach has ever included students both as panelists and researchers. MATERIAL AND METHODS: Four Delphi panels were developed and conducted using a participatory approach that allowed medical students to take part both as expert panelists and researchers: specifically, students developed the questionnaire and conducted a qualitative synthesis. Questionnaire responses were anonymized and dispatched online to panelists. The information was organized and collected to develop the qualitative syntheses and prepare the final statements. RESULTS: Thirty-two medical students participated between February and May 2018. A total of 32 questions were developed, corresponding to five different categories. For some questions, consensus was reached; for other questions, general statements were obtained.Discussion and conclusion: Developing the questionnaire, responding to it and analyzing the answers allowed students to raise significant concerns regarding medical education topics proposing relevant policy and curricula change. Participatory Delphi panels can be an efficient tool to obtain organized feedback, improve student class involvement, and promote research skills.

SARS-CoV-2 in river water: Implications in low sanitation countries.

Since the beginning of COVID-19 pandemic studies on viral shedding have reported that this virus is excreted in feces in most patients. High viral loads are found at the sewage pipeline or at the entrance of wastewater treatment plants from cities where the number of COVID-19 cases are significant. In Quito (Ecuador) as in many other cities worldwide, wastewater is directly discharged into natural waters. The aim of this study was to evaluate SARS-CoV-2 presence in urban streams from a low sanitation context. Three river locations along the urban rivers of Quito were sampled on the 5th of June during a peak of COVID-19 cases. River samples were evaluated for water quality parameters and afterwards, concentrated for viral analysis using skimmed milk flocculation method. The viral concentrates were quantified for SARS-CoV-2 (N1 and N2 target regions) and Human Adenovirus as a human viral indicator. The results showed that SARS-CoV-2 was detected for both target regions in all samples analyzed in a range of 2,91E+05 to 3,19E+06 GC/L for N1 and from 2,07E+05 to 2,22E+06 GC/L for N2. The high values detected in natural waters from a low sanitation region have several implications in health and ecology that should be further assessed.

Importance of ocular electrophysiology in the diagnosis of retinal dystrophies. / Importancia de la electrofisiología ocular en el diagnóstico de las distrofias retinianas.

BACKGROUND AND OBJECTIVE: The diagnosis of retinal dystrophies is complex and is based on complete ophthalmological study, genetic study and electrophysiological studies (EPS). In this study, we intend to evaluate the role of electrophysiological and medical tests in the diagnosis of retinal dystrophies. MATERIAL AND METHODS: A retrospective observational study was conducted on 50 selected patients that attended the Neurophysiology Department of the University Hospital Virgen Macarena. An analysis was made of the variables that included, gender, age, referral hospital, reason for which the EPS was requested, applied EPS, genetic study, presumed diagnosis, and definitive diagnosis after EPS. A classification system was subsequently developed, which gives each case a value between 0 and 2, depending on the contribution of the electrophysiological tests to the final diagnosis. RESULTS: The mean age was 44.34 ±18.03 years (60% women). Retinitis pigmentosa (24%), optic neuropathy (12%), and Stargardt's disease (8%) were the most frequent diagnoses. The EPS modified the presumed diagnosis in 48% of the cases, confirmed the diagnosis in 44%, and did not provide any useful information in 8%. The contribution of the EPS was greater in patients seen in the HUVM and when requested by findings in the examination (P=.001). The false positives in the diagnosis of retinal dystrophy were 60% in patients not evaluated by the University Hospital Virgen Macarena. CONCLUSIONS: Electrophysiological test and specialised management of patients with retinal dystrophies play an important role in the diagnosis of these conditions.

Fast update of undetected Mycobacterium chimaera infections to reveal unsuspected cases.

Mycobacterium chimaera is involved in a worldwide alert due to contaminated heater-cooler units. A real-time polymerase chain reaction (RT-PCR)-based procedure was implemented to survey undetected cases of M. chimaera infection. PCR was negative in the 59 prosthetic heart valves from patients with PCR-16SrRNA-negative infective endocarditis. PCR identified M. chimaera in one of 15 clinically significant retrospective Mycobacterium avium-Mycobacterium intracellulare complex isolates, which corresponded to a patient who had undergone heart valve replacement in a different institution. Whole-genome sequencing demonstrated that he was the first case in Spain with involvement of the strain responsible for the global outbreak. These results highlight the relevance of retrospective tracking for undetected M. chimaera infections.

Retinoblastoma: The importance of early diagnosis. / Retinoblastoma: la importancia de su diagnóstico precoz.

INTRODUCTION: Retinoblastoma is the most frequent malignant intraocular tumour in childhood, and both its cure and the sequelae arising from it, mainly depend on an early diagnosis. There is currently no consensus on its diagnostic and therapeutic management. PATIENTS AND METHODS: A descriptive, retrospective, and non-randomised study was conducted on a series of cases (39 patients -58 eyes), treated during the period 2006-2013, in the Regional Reference Centre for Tumours of the National Health Service Quality Agency. RESULTS: The most frequent presentation sign is leukocoria (71.8%), followed by strabismus (17.9%). All cases of bilateral tumour had a germline mutation of the RB1 gene, and 20% had a family history. Stage E was observed in 55% of the patients, and 90% required chemotherapy treatment. The eye was maintained in 57% of those who had mild stages, compared to 43% who maintained it in advanced stages. CONCLUSIONS: This analysis included 58 eyes. There are no previous studies in our community and there are few series so numerous throughout the country. Based on non-standardised treatment, the most appropriate is chosen according to the characteristics of the tumour. The multidisciplinary management, formed by ophthalmology, paediatric oncology, radiotherapy, and radiophysical oncology, is fundamental for the selection of the most appropriate treatment. Chemo-reduction, along with consolidation treatments, offers encouraging results in the control of these tumours, especially in those of less severity. Enucleation continues to be the method of choice in the most advanced staging with vitreous involvement, with the importance of early diagnosis being highlighted.

The optimal ethanol lock therapy regimen for treatment of biofilm-associated catheter infections: an in-vitro study.

BACKGROUND: Ethanol-based lock therapy (LT) solutions are used as an alternative to antibiotics for the conservative management of catheter-related bloodstream infection. However, no clear consensus on regimen or dose has been reached. AIM: To find the ethanol-based lock solution containing a sufficiently low concentration of ethanol for reduction of the metabolic activity of bacterial and fungal biofilms. METHODS: Using an in-vitro model, three concentrations of ethanol (25%, 40%, 70%) were tested, with and without 60 IU of heparin, at six different time-points and against 24 h preformed biofilms of Staphylococcus aureus ATCC29213, Staphylococcus epidermidis (clinical isolate), Enterococcus faecalis ATCC33186, Candida albicans ATCC14058, and Escherichia coli ATCC25922. The reduction in the metabolic activity of the biofilm was measured using the tetrazolium salt assay and LT was considered to be successful when metabolic activity fell by >90%. Regrowth inhibition was then tested within 24 h and seven days after each LT regimen only at the ethanol concentration of the most successful LT regimen. FINDINGS: The most successful LT was achieved with 40% ethanol + 60 IU of heparin only at 24, 72, and 24 h for seven-day regimens (P < 0.05). However, none of the regimens reached 45% RI within seven days of therapy. CONCLUSION: According to our in-vitro data, an ethanol-based lock solution with 40% ethanol + 60 IU heparin administered daily for 72 h is sufficient to almost eradicate the metabolic activity of bacterial and fungal biofilms. Future studies are needed to study cell regrowth after LT.

Biofilm production is not associated with poor clinical outcome in 485 patients with Staphylococcus aureus bacteraemia.

OBJECTIVES: Staphylococcus aureus biofilm may constitute a major cause of virulence. Our main objective was to analyse whether there was an association between biofilm production and poor outcome in patients with S. aureus bacteraemia. METHODS: We studied 485 S. aureus strains isolated from the blood of patients with bacteraemia from 2012 to 2015. We assessed in vitro biomass production using crystal violet assay and metabolic activity using tetrazolium salt assay. Strains were classified in tertile ranks as follows: low biomass producers, moderate biomass producers, high biomass producers, low metabolic activity, moderate metabolic activity and high metabolic activity. We excluded from analysis strains with moderate crystal violet and tetrazolium salt values. We defined poor outcome as fulfillment of one or more of the following conditions: 30-day attributable mortality, infective endocarditis, persistent bacteraemia and recurrent bacteraemia. RESULTS: Outcome was poor in 199 (41.0%) of 485 S. aureus bacteraemia episodes. The distribution of poor outcome with respect to biomass production and metabolic activity was as follows: low biomass producers, 36.6% vs. high biomass producers, 43.2% (p 0.26); and low metabolic activity, 43.5% vs. high metabolic activity, 36.2% (p 0.91). The presence of methicillin-resistant S. aureus was the only characteristic that was more likely to be present in the high metabolic activity group (17.4% vs. 39.3%, p < 0.001). CONCLUSIONS: Biofilm production, as determined by any of the methods used in the present study, is not associated with poor outcome in patients with S. aureus bacteraemia.

Alien species pathways to the Galapagos Islands, Ecuador.

Alien species, one of the biggest threats to natural ecosystems worldwide, are of particular concern for oceanic archipelagos such as Galápagos. To enable more effective management of alien species, we reviewed, collated and analysed all available records of alien species for Galápagos. We also assembled a comprehensive dataset on pathways to and among the Galápagos Islands, including tourist and resident numbers, tourist vessels, their itineraries and visitation sites, aircraft capacity and occupancy, air and sea cargo and biosecurity interceptions. So far, 1,579 alien terrestrial and marine species have been introduced to Galápagos by humans. Of these, 1,476 have become established. Almost half of these were intentional introductions, mostly of plants. Most unintentional introductions arrived on plants and plant associated material, followed by transport vehicles, and commodities (in particular fruit and vegetables). The number, frequency and geographic origin of pathways for the arrival and dispersal of alien species to and within Galápagos have increased over time, tracking closely the increase in human population (residents and tourists) on the islands. Intentional introductions of alien species should decline as biosecurity is strengthened but there is a danger that unintentional introductions will increase further as tourism on Galápagos expands. This unique world heritage site will only retain its biodiversity values if the pathways for invasion are managed effectively.

Should non-bacteraemic patients with a colonized catheter receive antimicrobial therapy?

OBJECTIVES: The impact of antimicrobial therapy on the outcomes of patients with colonized catheters and no bacteraemia has not been assessed. This study assessed whether targeted antibiotic therapy is related to a poor outcome in patients with positive cultures of blood drawn through a non-tunnelled central venous catheter (CVC) and without concomitant bacteraemia. METHODS: This was a retrospective study involving adult patients with positive blood cultures drawn through a CVC and negative peripheral vein blood cultures. Patients were classified into two groups: those with clinical improvement and those with a poor outcome. These two groups were compared. The outcome was considered poor in the presence of one or more of the following: death, bacteraemia or other infection due to the same microorganism, and evidence of catheter-related bloodstream infection. RESULTS: A total of 100 patients were included (31 with a poor outcome). The only independent predictors of a poor outcome were a McCabe and Jackson score of 1-2 and a median APACHE score of 5. No association was found between the use of targeted antimicrobial therapy and a poor outcome when its effect was adjusted for the rest of the variables. CONCLUSIONS: This study showed that antimicrobial therapy was not associated with a poor outcome in non-bacteraemic patients with positive blood cultures drawn through a CVC.

Nationwide study on peripheral-venous-catheter-associated-bloodstream infections in internal medicine departments.

BACKGROUND: The use of peripheral venous catheters (PVCs) has increased outside intensive care units, as has the rate of PVC-associated-bloodstream infection (PVC-BSI). PVCs are widely used in internal medicine departments (IMDs), but data on the incidence of PVC-BSI and its characteristics in IMDs are scarce. AIM: To assess the incidence of PVC-BSI episodes detected in IMDs in Spain. METHODS: A one-year multi-centre prospective observational cohort study in 14 Spanish IMDs was undertaken. Adult patients admitted with at least one PVC and bacteraemia were included in the study. Demographic and clinical data were provided by local coordinators. FINDINGS: Seventy episodes of PVC-BSI were recorded, representing an overall rate of 1.64 PVC-BSI episodes/1000 IMD admissions. The mean age of patients was 67.44 (standard deviation 16.72) years. It was estimated that 25.7% of PVCs were no longer necessary. Staphylococcus aureus was the most frequently isolated micro-organism (41.7%). Phlebitis was clinically evident in 44 (62.9%) episodes, and proved to be an independent predictor of catheter insertion in emergency departments (odds ratio 5.44). The crude and attributable mortality rates were 12.9% and 5.7%, respectively. CONCLUSIONS: PVCs carry a significant risk for bacteraemia in Spanish IMDs. Phlebitis is not always clinically evident in patients with bacteraemia in this population. The study findings support the need for educational and interventional preventive measures in both IMDs and emergency departments to reduce the rate of PVC-BSI and associated comorbidities, and costs.

Slicing silicone neonatal vascular catheter tips improves colonization detection by the roll-plate technique.

OBJECTIVE: Silicone neonatal peripherally inserted central catheters (SN-PICCs) are a common cause of catheter-related bloodstream infection (C-RBSI) in neonates. Our objective was to compare the yield of traditional roll-plate technique (TRP), roll-plate after slicing (RPS), and sonication after slicing (SS) for the detection of colonization and C-RBSI in SN-PICCs. METHODS: We prospectively cultured tips from SN-PICCs withdrawn from paediatric patients admitted to our institution with suspicion of infection. We first cultured the catheter tip using TRP and then divided the catheter into two segments. RPS was performed by longitudinally slicing one segment and the fragments were cultured. SS was performed by transversally slicing the other segment followed by culture after sonication. We calculated the validity values of each technique individually by comparing them with the diagnostic standard of colonization and C-RBSI. RESULTS: We included 162 SN-PICCs, 46 of which were colonized. Sensitivity rates for colonization and C-RBSI with TRP, RPS and SS were, respectively, 71.7%, 80.4% and 67.4%; and 74.2%, 90.3% and 77.4%. CONCLUSION: Catheter slicing should be performed before the roll-plate technique to ensure optimal diagnosis on SN-PICCs.