Imported malaria including HIV and pregnant woman risk groups: overview of the case of a Spanish city 2004-2014.

BACKGROUND: Arrival of inmigrants from malaria endemic areas has led to a emergence of cases of this parasitic disease in Spain. The objective of this study was to analyse the high incidence rate of imported malaria in Fuenlabrada, a city in the south of Madrid, together with the frequent the lack of chemoprophylaxis, for the period between 2004 and 2014. Both pregnant women and HIV risk groups have been considered. METHODS: Retrospective descriptive study of laboratory-confirmed malaria at the Fuenlabrada University Hospital, in Madrid, during a 10-year period (2004-2014). These data were obtained reviewing medical histories of the cases. Relevant epidemiological, clinical and laboratory results were analysed, with focus on the following risk groups: pregnant women and individuals with HIV. RESULTS: A total of 185 cases were diagnosed (90.3 % Plasmodium falciparum). The annual incidence rate was 11.9/100,000 inhabitants/year. The average age was 30.8 years (SD: 14.3). Infections originating in sub-Saharan Africa comprised the 97.6 % of the cases. A total of 85.9 % were Visiting Friends and Relatives. Only a 4.3 % completed adequate prophylaxis. A total of 14.28 % of the fertile women were pregnant, and 8 cases (4.3 %) had HIV. None of them in these special groups completed prophylaxis. CONCLUSIONS: The incidence rate in Fuenlabrada is higher than in the rest of Spain, due to the large number of immigrants from endemic areas living in the municipality. However, the results are not representative of all the country. It seems to be reasonable to implement prevention and pre-travel assessment programs to increase chemoprophylaxis. Pregnancy tests and HIV serology should be completed for all patients to improve prophylactic methods.

Clinical diagnostic accuracy of suspected sources of bacteremia and its effect on mortality.

BACKGROUND: Although much has been written about bacteremia, evidence of the clinical diagnostic accuracy of bacteremia sources in the absence of microbiological results and the impact of diagnostic accuracy on mortality is scarce. METHODS: This is a retrospective study of bacteremia episodes over a 2-year period at a general hospital in Madrid. Congruence analyses between clinically presumed and definite sources, acquisition, causative organism, empirical treatment and progression to death were performed. RESULTS: The study included 323 bacteremia episodes. Clinicians' diagnostic accuracy was higher for gastrointestinal (88.8%; 95% CI: 79%-84%), respiratory (93.9%; 95% CI: 79%-99%) and urinary tract sources (83.6%; 95% CI: 75%-89%) and lower for skin and soft tissues (77.2%; 95% CI: 54%-92%) and, notably, intravascular sources (56%; 95% CI: 39%-71%). Overall, a non-significant (3.45%; 95% CI: -0.6%-13.5%, p=0.47) increase in mortality was observed in the incorrectly suspected bacteremia source group. Mortality related to a definitive source was significantly higher when an intravascular origin was not suspected, resulting in a 26% increase in mortality (95% CI: 1%-52%, p=0.03). Differences in mortality related to inaccurate source assumptions were non-significant when the definitive bacteremia sources were gastrointestinal, urinary, respiratory, skin and soft tissues or unknown. Mortality in the group receiving appropriate empirical antimicrobial treatment was 10.6% compared with 19.7% mortality in the group receiving inappropriate empirical antimicrobial treatment (OR 2; 95% CI: 1.01-4.25). CONCLUSIONS: The diagnostic accuracy of bacteremia sources is high in all but intravascular sources. A non-suspected intravascular source and inappropriate empirical treatment are related to a higher mortality.

Modelo clínico predictivo y validación de bacteriemias por anaerobios (incluidas las bacteriemias polimicrobianas) / Clinic predictive model and validation of anaerobic bacteremias (including polymicrobial bacteremias)

Introducción Las bacteriemias por microorganismos anaerobios son poco frecuentes, no existiendo consenso sobre su predictibilidad clínica y la utilidad rutinaria de los medios de cultivo para anaerobios. El objetivo del estudio es crear y validar un modelo predictivo de bacteriemia por anaerobios. Métodos El modelo predictivo se realizó con 984 bacteriemias (45 anaerobios estrictos) durante 1985–86 y 1996–97. La validación durante 2005–06 con 320 bacteriemias. Resultados Los factores predictores de bacteriemia por anaerobios calculados en el análisis multivariante para la creación de un modelo estratificado con puntuaciones de 0–13 puntos (p) fueron: origen desconocido (OR: 3,46; IC 95%: 1,13–10,54) 3 p; origen abdominal y cutáneo (OR: 14,85; IC 95%: 6,37–34,62) 6 p; hipotensión (OR: 1,99; IC 95%: 0,98–4,04) 2 p; ausencia de manipulaciones vasculares (OR: 2,62; IC 95%: 1,04–6,60) 2 p y edad >60 años (OR: 3,21; IC 95%: 1,19–8,67) 3 p. Con >7 p el modelo tiene S:77,8%, E:78,3%, VPP: 14,7% y un VPN del 98,6%, área bajo curva ROC=0,84 (EE=0,011). IC 95%: 0,82–0,86 con prevalencia de bacteriemia por anaerobios estimada 4,6%. La validación del modelo se realizó con 320 bacteremias (55 de ellas por anaerobios estrictos). El 83,6% (IC 95%: 71,19–92,23) de las bacteriemias por anaerobios tienen >7 p, y el 72,7% tienen 9 p o más. El 26,4% (IC 95%: 21,2–32,15) de las bacteriemias por aerobios y aerobios-anaerobios facultativos tienen >7 p, y solo el 11,7% tienen 9 p o más.Área bajo curva ROC=0,82 (EE=0,02). IC 95%: 0,78–0,86. Prevalencia estimada 2%.ConclusionesEl origen abdominal y cutáneo OR 14,85; origen desconocido OR 3,46; hipotensión OR 1,99; ausencia de manipulaciones vasculares OR 2,62 y edad >60 años OR 3,21 permiten crear un modelo clínico predictivo de bacteriemia por anaerobios con alta S y E. Por su baja prevalencia la importancia del modelo radica en su altísimo valor predictivo negativo (AU)

Introduction Anaerobic bacteremias are uncommon. There is no agreement on their clinical predictability and the usefulness of anaerobic blood cultures. The objective of this study was to develop and validate a model for the prediction of anaerobic bacteremias. Method The developing model was created with 984 bacteremias (45 anaerobic bacteremias) during 1985–1986 and 1996–1997. The validation model was made with 320 bacteremias during 2005–2006.ResultsIndependent multivariate predictors of true anaerobic bacteremia were used to develop a model stratifying patients with scores of 0 to 13 points(p), which were: unknown focus OR 3.46 (CI: 1.13–10.54) 3 p; abdominal and skin focus OR 14.85 (CI: 6.37–34.62) 6p; hypotension OR 1.99 (CI: 0.98–4.04) 2p; absence of vascular manipulations OR 2.62 (CI: 1.04–6.60) 2p and age over 60 years OR 3.21 (CI: 1.19–8.67) 3p. In the derivation sets group with more than 7p the model had Sensitivity: 77.8%, Specificity: 78.3%, PPV:14.7%, and a NPV of 98.6%. The area under curve was ROC=0.84 (SE=0.011), 95% CI: 0.82–0.86 (..) (AU)

[Clinic predictive model and validation of anaerobic bacteremias (including polymicrobial bacteremias)]. / Modelo clínico predictivo y validación de bacteriemias por anaerobios (incluidas las bacteriemias polimicrobianas).

INTRODUCTION: Anaerobic bacteremias are uncommon. There is no agreement on their clinical predictability and the usefulness of anaerobic blood cultures. The objective of this study was to develop and validate a model for the prediction of anaerobic bacteremias. METHOD: The developing model was created with 984 bacteremias (45 anaerobic bacteremias) during 1985-1986 and 1996-1997. The validation model was made with 320 bacteremias during 2005-2006. RESULTS: Independent multivariate predictors of true anaerobic bacteremia were used to develop a model stratifying patients with scores of 0 to 13 points(p), which were: unknown focus OR 3.46 (CI: 1.13-10.54) 3 p; abdominal and skin focus OR 14.85 (CI: 6.37-34.62) 6p; hypotension OR 1.99 (CI: 0.98-4.04) 2p; absence of vascular manipulations OR 2.62 (CI: 1.04-6.60) 2p and age over 60 years OR 3.21 (CI: 1.19-8.67) 3p. In the derivation sets group with more than 7p the model had Sensitivity: 77.8%, Specificity: 78.3%, PPV:14.7%, and a NPV of 98.6%. The area under curve was ROC=0.84 (SE=0.011), 95% CI: 0.82-0.86 with an anaerobic bacteremia prevalence of 4.6%. The validation set was studied analysing 320 bacteremias. Of these, 83.6% (95% CI: 71.19%-92.23%) of anaerobic bacteremias had more than 7 points, and 72.7% had more than 9 points. There was 26.4% (95% CI: 21.2%-32.15%) aerobic and facultative anaerobic bacteremias with more than 7 points, and only the 11.7% with 9 or more points. The area under the curve was, ROC=0.82 (SE=0.02), 95% CI:0.78-0.86, and estimated prevalence, 2%. CONCLUSIONS: Abdominal and skin focus OR 14,85; unknown focus OR 3,46; hypotension OR 1,99; absence of vascular manipulations OR 2,62 and age over 60 years enable us to make a predictive clinical model of probability of anaerobic bacteremia with a high sensitivity and specificity. The model particularly has a significant predictive negative value due to the low prevalence of anaerobic bacteremia.

Rentabilidad diagnóstica de los medios de cultivo para anaerobios en bacteriemias en una unidad de cuidados intensivos / Diagnostic reliability of anaerobic blood cultures in bacteremias from a critical care unit

Fundamento y objetivo: Estudio descriptivo de las bacteriemias diagnosticadas en una unidad de cuidados intensivos (UCI) medicoquirúrgica y comparación de la rentabilidad diagnóstica de los hemocultivos en aerobiosis y anaerobiosis. Pacientes y método: Análisis de todos los hemocultivos con crecimiento extraídos en una UCI medicoquirúrgica desde mayo de 2005 hasta octubre de 2007. Resultados: La incidencia de la bacteriemia fue del 6,1% de los ingresos. Cien pacientes presentaron algún crecimiento en los hemocultivos extraídos, diagnosticándose 73 bacteriemias y 52 contaminantes. Los hemocultivos contaminantes se extrajeron 6,27 días antes (intervalo de confianza [IC] del 95%: 0,61 a 11,94; p=0,03) que los hemocultivos significativos. Los microorganismos más frecuentes causantes de bacteriemia fueron cocos grampositivos en 43 casos (58,9%) (estafilococos coagulasa negativos en 30 casos [41%]) (p=0,001) y candidemias en 10 casos (13,7%). No hubo bacteriemias por anaerobios. El origen más frecuente fue el catéter con 36 casos (49,3%; p<0,005) seguido del digestivo con 14 casos (19,2%). De los microorganismos causantes de las 73 bacteriemias, 66 (90,4%) crecieron en aerobiosis y 58 (79,5%) en anaerobiosis (diferencia del 10,9%; p=0,06). Analizando sólo las bacteriemias de adquisición intrahospitalaria, hay una diferencia del 13,56% (IC del 95%: del 0,8 al 26%) a favor de los crecimientos en aerobiosis (p=0,04). Las candidemias presentaron crecimiento sólo en aerobiosis (p=0,001). Analizando los estafilococos coagulasa negativos (30 bacteriemias y 41 contaminantes), 62 (87,3%) crecieron en aerobiosis y 50 (70,4%) en anaerobiosis (diferencia del 16,9%, IC del 95%: del 3 al 30%; p=0,01) (AU)

Background and objective. This is a descriptive study of bacteraemias diagnosed in ICU with an analysis of the diagnostic reliability of anaerobic blood cultures. Patients and method. Analysis of all positive blood cultures in an Intensive Care Unit from May 2005 to October 2007. Results. The overall incidence of true bacteraemia was 6,1% of admissions. Out of 100 patients, there were 73 bacteraemias and 52 contaminated cultures. Samples with contaminated cultures were drawn 6,27 days earlier (CI 95% 0,61–11,94 Sig:0,03) than true bacteraemia. Most frequent micro organisms were cocci gram positive: 43 cases (58,9%) (coagulase-negative staphylococci was the most frequent: 30 or 41% of all bacteraemia)) Sig=0,001 in relation with gram negatives. Anaerobic micro organisms were not detected. Candidemias were found in 10 cases (13,7%). The most frequent causes of bacteraemia in this study were catheter-related infections with 36 cases (49,3% Sig<0,005), followed by digestive origin infections in 14 (19,2%). Of all bacteremic episodes (73 bacteraemia), 66 (90,4%) were isolated in aerobic blood cultures, and 58 (79,5%) were in anaerobic ones, with a difference of 10,9% Sig:0,06. When only intrahospitalary bacteraemias were analyzed, there was a difference of 13,56% of more yields in aerobic blood cultures; Sig:0,04 (IC 95% 0,8%–26%)). Candidemias were isolated only in aerobic blood cultures; Sig:0,001. When analyzing coagulase negative staphylococci, there were 30 bacteraemias and 41 contaminated samples. 62 (87,3%) were isolated in aerobic blood cultures and 50 (70,4%) in anaerobic ones, with a difference of 16,9% Sig=0,01,CI 95%(3%–30%).ConclusionsIn the Critical Care Unit, it would be possible to change the anaerobic blood cultures by aerobic ones to diagnose bacteraemias of intrahospitalary acquisition. This fact should be analyzed with others studies (AU)

[Diagnostic reliability of anaerobic blood cultures in bacteremias from a critical care unit]. / Rentabilidad diagnóstica de los medios de cultivo para anaerobios en bacteriemias en una unidad de cuidados intensivos.

BACKGROUND AND OBJECTIVE: This is a descriptive study of bacteraemias diagnosed in ICU with an analysis of the diagnostic reliability of anaerobic blood cultures. PATIENTS AND METHOD: Analysis of all positive blood cultures in an Intensive Care Unit from May 2005 to October 2007. RESULTS: The overall incidence of true bacteraemia was 6,1% of admissions. Out of 100 patients, there were 73 bacteraemias and 52 contaminated cultures. Samples with contaminated cultures were drawn 6,27 days earlier (CI 95% 0,61-11,94 Sig:0,03) than true bacteraemia. Most frequent micro organisms were cocci gram positive: 43 cases (58,9%) (coagulase-negative staphylococci was the most frequent: 30 or 41% of all bacteraemia)) Sig=0,001 in relation with gram negatives. Anaerobic micro organisms were not detected. Candidemias were found in 10 cases (13,7%). The most frequent causes of bacteraemia in this study were catheter-related infections with 36 cases (49,3% Sig<0,005), followed by digestive origin infections in 14 (19,2%). Of all bacteremic episodes (73 bacteraemia), 66 (90,4%) were isolated in aerobic blood cultures, and 58 (79,5%) were in anaerobic ones, with a difference of 10,9% Sig:0,06. When only intrahospitalary bacteraemias were analyzed, there was a difference of 13,56% of more yields in aerobic blood cultures; Sig:0,04 (IC 95% 0,8%-26%)). Candidemias were isolated only in aerobic blood cultures; Sig:0,001. When analyzing coagulase negative staphylococci, there were 30 bacteraemias and 41 contaminated samples. 62 (87,3%) were isolated in aerobic blood cultures and 50 (70,4%) in anaerobic ones, with a difference of 16,9% Sig=0,01,CI 95%(3%-30%). CONCLUSIONS: In the Critical Care Unit, it would be possible to change the anaerobic blood cultures by aerobic ones to diagnose bacteraemias of intrahospitalary acquisition. This fact should be analyzed with others studies.