Pseudomonas aeruginosa Bloodstream Infections Presenting with Septic Shock in Neutropenic Cancer Patients: Impact of Empirical Antibiotic Therapy.

This large, multicenter, retrospective cohort study including onco-hematological neutropenic patients with Pseudomonas aeruginosa bloodstream infection (PABSI) found that among 1213 episodes, 411 (33%) presented with septic shock. The presence of solid tumors (33.3% vs. 20.2%, p < 0.001), a high-risk Multinational Association for Supportive Care in Cancer (MASCC) index score (92.6% vs. 57.4%; p < 0.001), pneumonia (38% vs. 19.2% p < 0.001), and infection due to multidrug-resistant P. aeruginosa (MDRPA) (33.8% vs. 21.1%, p < 0.001) were statistically significantly higher in patients with septic shock compared to those without. Patients with septic shock were more likely to receive inadequate empirical antibiotic therapy (IEAT) (21.7% vs. 16.2%, p = 0.020) and to present poorer outcomes, including a need for ICU admission (74% vs. 10.5%; p < 0.001), mechanical ventilation (49.1% vs. 5.6%; p < 0.001), and higher 7-day and 30-day case fatality rates (58.2% vs. 12%, p < 0.001, and 74% vs. 23.1%, p < 0.001, respectively). Risk factors for 30-day case fatality rate in patients with septic shock were orotracheal intubation, IEAT, infection due to MDRPA, and persistent PABSI. Therapy with granulocyte colony-stimulating factor and BSI from the urinary tract were associated with improved survival. Carbapenems were the most frequent IEAT in patients with septic shock, and the use of empirical combination therapy showed a tendency towards improved survival. Our findings emphasize the need for tailored management strategies in this high-risk population.

Pseudomonas aeruginosa Bloodstream Infections in Patients with Cancer: Differences between Patients with Hematological Malignancies and Solid Tumors.

Objectives: To assess the clinical features and outcomes of Pseudomonas aeruginosa bloodstream infection (PA BSI) in neutropenic patients with hematological malignancies (HM) and with solid tumors (ST), and identify the risk factors for 30-day mortality. Methods: We performed a large multicenter, retrospective cohort study including onco-hematological neutropenic patients with PA BSI conducted across 34 centers in 12 countries (January 2006−May 2018). Episodes occurring in hematologic patients were compared to those developing in patients with ST. Risk factors associated with 30-day mortality were investigated in both groups. Results: Of 1217 episodes of PA BSI, 917 occurred in patients with HM and 300 in patients with ST. Hematological patients had more commonly profound neutropenia (0.1 × 109 cells/mm) (67% vs. 44.6%; p < 0.001), and a high risk Multinational Association for Supportive Care in Cancer (MASCC) index score (32.2% vs. 26.7%; p = 0.05). Catheter-infection (10.7% vs. 4.7%; p = 0.001), mucositis (2.4% vs. 0.7%; p = 0.042), and perianal infection (3.6% vs. 0.3%; p = 0.001) predominated as BSI sources in the hematological patients, whereas pneumonia (22.9% vs. 33.7%; p < 0.001) and other abdominal sites (2.8% vs. 6.3%; p = 0.006) were more common in patients with ST. Hematological patients had more frequent BSI due to multidrug-resistant P. aeruginosa (MDRPA) (23.2% vs. 7.7%; p < 0.001), and were more likely to receive inadequate initial antibiotic therapy (IEAT) (20.1% vs. 12%; p < 0.001). Patients with ST presented more frequently with septic shock (45.8% vs. 30%; p < 0.001), and presented worse outcomes, with increased 7-day (38% vs. 24.2%; p < 0.001) and 30-day (49% vs. 37.3%; p < 0.001) case-fatality rates. Risk factors for 30-day mortality in hematologic patients were high risk MASCC index score, IEAT, pneumonia, infection due to MDRPA, and septic shock. Risk factors for 30-day mortality in patients with ST were high risk MASCC index score, IEAT, persistent BSI, and septic shock. Therapy with granulocyte colony-stimulating factor was associated with survival in both groups. Conclusions: The clinical features and outcomes of PA BSI in neutropenic cancer patients showed some differences depending on the underlying malignancy. Considering these differences and the risk factors for mortality may be useful to optimize their therapeutic management. Among the risk factors associated with overall mortality, IEAT and the administration of granulocyte colony-stimulating factor were the only modifiable variables.

Effect of Combination Antibiotic Empirical Therapy on Mortality in Neutropenic Cancer Patients with Pseudomonas aeruginosa Pneumonia.

To assess the effect of combination antibiotic empirical therapy on 30-day case-fatality rate in neutropenic cancer patients with Pseudomonas aeruginosa (PA) bacteremic pneumonia. This was a multinational, retrospective cohort study of neutropenic onco-hematological patients with PA bloodstream infection (BSI) (2006−2018). The effect of appropriate empirical combination therapy, appropriate monotherapy and inappropriate empirical antibiotic therapy [IEAT] on 30-day case-fatality was assessed only in patients with PA bacteremic pneumonia. Among 1017 PA BSI episodes, pneumonia was the source of BSI in 294 (28.9%). Among those, 52 (17.7%) were caused by a multidrug-resistant (MDR) strain and 68 (23.1%) received IEAT, mainly when the infection was caused by an MDR strain [38/52 (73.1%) vs. 30/242 (12.4%); p < 0.001]. The 30-day case-fatality rate was higher in patients with PA bacteremic pneumonia than in those with PA BSI from other sources (55.1% vs. 31.4%; p < 0.001). IEAT was associated with increased 30-day case-fatality (aHR 1.44 [95%CI 1.01−2.03]; p = 0.042), whereas the use of appropriate combination empirical treatment was independently associated with improved survival (aHR 0.46 [95%CI 0.27−0.78]; p = 0.004). Appropriate empirical monotherapy was not associated with improved overall survival (aHR 1.25 [95%CI 0.76−2.05]; p = 0.39). Combination antibiotic empirical therapy should be administered promptly in febrile neutropenic patients with suspected pneumonia as the source of infection.

Ileal obstruction caused by transmural endometriosis in a patient with simultaneous C. difficile colitis and Influenza AH1N1. Case report.

INTRODUCTION: Small bowel obstruction secondary to endometriosis is extremely rare. This etiology is reported in 0.10% of cases and diagnosed incidentally. CASE PRESENTATION: 32-year old female, critically ill patient was diagnosed with small bowel obstruction. After medical stabilization of multiple comorbidities, diagnostic laparoscopy was done and converted to open right ileocolectomy with ileo-transverse anastomosis. Definite diagnosis was ileal obstruction caused by transmural endometriosis. The patient's recovery was uneventful. At one-year follow-up, she remains asymptomatic. DISCUSSION: We present the uncommon case of ileal obstruction due to transmural endometriosis that was treated surgically. We also present current literature review focusing on diagnostic and treatment methods of this rare disease. CONCLUSION: Endometriosis should be included in the differential diagnosis of small bowel obstruction. The treatment of choice is bowel resection.

Impact of antibiotic resistance on outcomes of neutropenic cancer patients with Pseudomonas aeruginosa bacteraemia (IRONIC study): study protocol of a retrospective multicentre international study.

INTRODUCTION: Pseudomonas aeruginosa (PA) has historically been one of the major causes of severe sepsis and death among neutropenic cancer patients. There has been a recent increase of multidrug-resistant PA (MDRPA) isolates that may determine a worse prognosis, particularly in immunosuppressed patients. The aim of this study is to establish the impact of antibiotic resistance on the outcome of neutropenic onco-haematological patients with PA bacteraemia, and to identify the risk factors for MDRPA bacteraemia and mortality. METHODS AND ANALYSIS: This is a retrospective, observational, multicentre, international study. All episodes of PA bacteraemia occurring in neutropenic onco-haematological patients followed up at the participating centres from 1 January 2006 to 31 May 2018 will be retrospectively reviewed. The primary end point will be overall case-fatality rate within 30 days of onset of PA bacteraemia. The secondary end points will be to describe the following: the incidence and risk factors for multidrug-resistant and extremely drug-resistant PA bacteraemia (by comparing the episodes due to susceptible PA with those produced by MDRPA), the efficacy of ceftolozane/tazobactam, the rates of persistent bacteraemia and bacteraemia relapse and the risk factors for very early (48 hours), early (7 days) and overall (30 days) case-fatality rates. ETHICS AND DISSEMINATION: The Clinical Research Ethics Committee of Bellvitge University Hospital approved the protocol of the study at the primary site. To protect personal privacy, identifying information of each patient in the electronic database will be encrypted. The processing of the patients' personal data collected in the study will comply with the Spanish Data Protection Act of 1998 and with the European Directive on the privacy of data. All data collected, stored and processed will be anonymised. Results will be reported at conferences and in peer-reviewed publications.

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

Efficacy of ß-Lactam/ß-Lactamase Inhibitor Combinations for the Treatment of Bloodstream Infection Due to Extended-Spectrum-ß-Lactamase-Producing Enterobacteriaceae in Hematological Patients with Neutropenia.

ß-Lactam/ß-lactamase inhibitors (BLBLIs) were compared to carbapenems in two cohorts of hematological neutropenic patients with extended-spectrum-ß-lactamase (ESBL) bloodstream infection (BSI): the empirical therapy cohort (174 patients) and the definitive therapy cohort (251 patients). The 30-day case fatality rates and other secondary outcomes were similar in the two therapy groups of the two cohorts and also in the propensity-matched cohorts. BLBLIs might be carbapenem-sparing alternatives for the treatment of BSI due to ESBLs in these patients.

Echinocandins Compared to Fluconazole for Candidemia of a Urinary Tract Source: A Propensity Score Analysis.

BACKGROUND: Whether echinocandins could be used to treat candidemia of a urinary tract source (CUTS) is unknown. We aimed to provide current epidemiological information of CUTS and to compare echinocandin to fluconazole treatment on CUTS outcomes. METHODS: A multicenter study of adult patients with candidemia was conducted in 9 hospitals. CUTS was defined as a candidemia with concomitant candiduria by the same organism associated with significant urological comorbidity. The primary outcome assessed was clinical failure (defined by 7-day mortality or persistent candidemia) in patients treated with either an echinocandin or fluconazole. A propensity score was calculated and then entered into a regression model. RESULTS: Of 2176 episodes of candidemia, 128 were CUTS (5.88%). Most CUTS cases were caused by Candida albicans (52.7%), followed by Candida glabrata (25.6%) and Candida tropicalis (16.3%). Clinical failure occurred in 7 patients (20%) treated with an echinocandin and in 15 (17.1%) treated with fluconazole (P = .730). Acute renal failure (adjusted odds ratio [AOR], 3.01; 95% confidence interval [CI], 1.01-8.91; P = .047) was the only independent factor associated with clinical failure, whereas early urinary tract drainage procedures (surgical, percutaneous, or endoscopic) were identified as protective (AOR, 0.08; 95% CI, .02-.31; P < .001). Neither univariate nor multivariate analysis showed that echinocandin therapy altered the risk of clinical failure. CONCLUSIONS: Initial echinocandin therapy was not associated with clinical failure in patients with CUTS. Notably, acute renal failure predicted worse outcomes and performing an early urologic procedure was a protective measure.

Effect of statin use on outcomes of adults with candidemia.

BACKGROUND: Statins have immunomodulatory properties and hinder Candida growth. However, it is unknown whether they may improve prognosis in patients with candidemia. We sought to determine the effect of prior statin use on the clinical outcomes of patients suffering candidemia. METHODS AND FINDINGS: Multicenter cohort study of hospitalized adults with candidemia between 2005 and 2011 in six hospitals in Spain, Brazil and Argentina. Of 326 candidemias, 44 (13.5%) occurred in statin users and 282 (86.5%) in statin non-users. The median value of APACHE II at candidemia diagnosis was similar between groups (18 vs. 16; p=.36). Candida albicans was the most commonly isolated species, followed by C. parapsilosis, C. tropicalis, C. glabrata, and C. krusei. There were no differences regarding appropriate empirical antifungal treatment. Statin users had a lower early (5 d) case-fatality rate than non-users (4.5 vs. 17%; p=.031). This effect was not observed with other cardiovascular drugs (aspirin, beta blockers and ACE inhibitors). Independent factor related to early case-fatality rate was APACHE II score (AOR, 1.08; 95% CI, 1.03-1.14; p=.002). An appropriate empirical antifungal therapy (AOR, 0.11; 95% CI, 0.04-0.26; p=<.001) and prior statin use were independently associated with lower early case-fatality (AOR, 0.17; 95% CI, 0.03-0.93; p=.041). Fourteen days (14d) and overall (30d) case-fatality rates were similar between groups (27% vs. 29%; p=0.77 and 40% vs. 44%; p=.66). CONCLUSIONS: The use of statins might have a beneficial effect on outcomes of patients with candidemia. This hypothesis deserves further evaluation in randomized trials.

Bacteriemia nosocomial en servicios de Cuidados Críticos y en Sala General / Nosocomial bloodstream infection in critical care units and in general wards

Introducción: las bacteriemias nosocomiales (BN) están ampliamente estudiadas en servicios de cuidados críticos, principalmente la relacionada a catéteres venosos centrales (CVC). La importancia de las BN y su impacto clínico no ha sido estudiada en salas generales de internación, en donde es cada vez mayor el uso de CVC y existe un uso extendido de catéteres venosos periféricos (CVP). Objetivo: nos propusimos comparar la BN ocurridas en salas de cuidados generales y en éreas de cuidados críticos. Métodos: estudio prospectivo descriptivo de BN desde 01/12/2008 hasta 30/06/2012, en un hospital de adultos de tercer nivel con 400 camas. Resultados: se registraron 361 bacteriemias: 50,9% nosocomiales, 16,1% relacionadas al sistema de salud y 32,9% comunitarias. De 184 BN se presentaron 52 episodios (28,3%) en servicios de cuidados críticos y 132 (71,3% en Sala General, principalmente en Clínica Médica (82,5%). El foco más frecuente de las BN fue asociado a catéteres venosos (60%) y foco desconocido (28%). Los porcentajes de multirresistencia fueron similares en ambos ámbitos. No hubo diferencias estadísticamente significativas en los Servicios de Cuidados Críticos comparado con la mortalidad por BN en Sala General (46,1% vs 46,9%; p=0,99). Conclusiones: el mayor porcentaje de BN se presentó en servicios de cuidados no críticos, su impacto es relevante si consideramos que la mortalidad intrahospitalaria resultó similar a la de servicios de cuidados críticos. Siendo la principal causa de BN en sala general, la relacionada al uso de catéter venoso central y periférico, urge la necesidad de diseñar protocolos para su colocación y manejo.

Introduction: Nosocomial Bloodstream Infections (NBI) are completely studied in critical care units, mainly those associated with central venous catheter (CVC). The significance and impact of NBI has not been analyzed in general wards, where there is an incresing use of CVC as well asan extended use of peripheral lines. Objective: we compared NBI in general wards with those occurred in critical care units. Methods: prospective, descriptive study performed from 01/12/2008 since 30/06/2012, in an adult third level 400-bed hospital. Results: we obtained 361 bloodstream infections: 50.9% nosocomial, 16.1% healthcare related and 32.9% community acquired. Out of 184 NBI episodes 52 (28.3%) were from critical care units and 132 (71,3%) from general wards, mainly internal medicine service (82.5%). The most frequent source of NBI was related to venous catheters (60%) and unknown focus (28%). Frequency of multirresistant microorganisms was similar in both areas. No statistically significant differences were found in the in-hospital mortality of NBI in critical care units and general wards (46.1% vs 46.9%; p=0.99). Conclusion: General wards presented the highest percentage of NBI. Its impact is relevant considering that the in-hospital mortality was similar tothat in critical care units. The main cause of NBI in general wards is that associated to the use of venous catheter, central and peripheral ones, therefore recommendations for catheterization and maintenance of venous catheters should be implemented.

Endometritis puerperal en nuestro medio / Postpartum endometritis incidence and risk factors

la infección genital postparto causa importante morbimortalidad. Se realizó un estudio de cohortes prospectivo observacional, que incluyó pacientes con parto vaginal o abdominal desde 19/04/2010 hasta 19/07/2010, para determinar la incidencia de endometritis y delimitar la población en riesgo. Se definió endometritis con al menos 2 de los siguientes: temperatura >38ºC, dolor uterino, dolor abdominal, loquios fétidos o ecografía patológica, sin otra causa de infección. Se registraron 1.472 partos. La inicidencia global de endometritis fue 2,5% (IC95%: 1,7-3,3); en partos vaginales 1,4% (IC95%: 0,7 - 2,1) y abdominales 4,8% (IC95%: 2,9-6,8). la diferencia fue estadísticamente significativa (p<0,001). En el análisis multivariado los factores de riesgo independientemente asociados fueron edad menor a 20 años y parto abdominal. Se descartó colinealidad entre ambas variables. Parto abdominal fue el único factor modificable. En este sentido deberían dirigirse las medidas de prevención y vigilancia.

Postpartum infection is cause of morbidity and mortality. To determine the incidence of postpartum endometritis and define the population at risk we performed a prospective observational study that included all the patients admitted for delivery to the Maternity service between 19/04/2010 and 19/07/2010. Endometritis was defined by at least two of the sequent: temperature >38ºC, uterine and lower abdominal pain, abnormal vaginal or cervical discharge or transvaginal ultrasound pathological findings. We registered 1,472 deliveries. Global incidence of postpartum endometritis was 2.5 % (95% Cl: 1.7-3.3); for spontaneous labor it was 1.4% (95% Cl:-2.1) and for cesarean deliveries 4.8% (95 %CL: 2.9-6.8) and this difference was statistically significant (p<0.001). Independent risk factors were age of 20 years or less and cesrean delivery. There was no colineality between both variables. Cesarean delivery was found the only modifiable risk factor for endometritis.

Influence of prior pneumococcal and influenza vaccination on outcomes of older adults with community-acquired pneumonia.

OBJECTIVES: To determine whether prior pneumococcal and seasonal influenza vaccination improves outcomes in older adults hospitalized for community-acquired pneumonia (CAP). DESIGN: Prospective, observational, multicenter study. SETTING: Five public hospitals providing universal free care to the whole population in three Spanish regions. PARTICIPANTS: Individuals aged 65 and older admitted to the hospital with CAP through the emergency department. MEASUREMENTS: Pneumococcal and influenza vaccination status. The primary study outcomes were intensive care unit (ICU) admission, length of hospital stay (LOS), and overall case-fatality rate. Outcome variables of individuals vaccinated with both vaccines were compared with outcomes of those who were unvaccinated. RESULTS: Two hundred thirty-eight individuals had received 23-valent pneumococcal polysaccharide vaccine and seasonal influenza vaccination and were compared with 195 unvaccinated individuals. No differences were found with respect to combined antibiotic therapy between groups (38.0% vs 39.7%; P = .80). Similar percentages of vaccinated and unvaccinated individuals required ICU admission (7.2% vs 8.2%; P = .69). Mean LOS was significantly shorter in vaccinated individuals (9.9 vs 12.4 days; P = .04). Overall case-fatality rates were similar in both groups (5.9% vs 5.1%; P = .73). After adjustment, LOS, risk of ICU admission, and overall case-fatality rate were not associated with prior pneumococcal and seasonal influenza vaccination. CONCLUSION: The clinical outcomes of vaccinated older adults hospitalized with CAP were not better than those observed in unvaccinated individuals.

Influence of carbapenem resistance on mortality and the dynamics of mortality in Pseudomonas aeruginosa bloodstream infection.

OBJECTIVE: We aimed to study the influence of carbapenem resistance on attributable mortality in a cohort of patients with Pseudomonas aeruginosa bacteremia. METHODS: Data on 121 episodes of P. aeruginosa bacteremia occurring between January and December 2005 were retrospectively analyzed. RESULTS: Thirty-three episodes were caused by carbapenem-resistant P. aeruginosa (CRPA) strains and 88 by carbapenem-susceptible P. aeruginosa (CSPA) strains. There was no significant difference in mortality between the groups (33% in CRPA vs. 30% in CSPA; p = 0.69). However, a Kaplan-Meier survival analysis showed that in the first 48h after the onset of bacteremia, there was a lower cumulative mortality proportion in the CRPA group than in the CSPA group (13% vs. 50%; p = 0.026). The independent risk factors associated with death in P. aeruginosa bacteremia were clinical presentation with severe sepsis (odds ratio (OR) 38, 95% confidence interval (CI) 10.2-142.2) and bacteremia of high-risk origin (OR 6.6, 95% CI 1.6-26.9). CONCLUSIONS: According to our data, carbapenem resistance was not associated with higher mortality in patients with P. aeruginosa bacteremia. The slower initial mortality in the CRPA group might have implications in the design of the optimal antibiotic policy strategy.

Validity of self-reported pneumococcal vaccination status in the elderly in Spain.

The objective of this study was to evaluate the validity of information reported by the elderly on 23-valent pneumococcal polysaccharide vaccine (23vPPV) vaccination status. A cross-sectional, observational study was carried out in patients aged >or=65 years admitted to five Spanish hospitals. Data on 23vPPV vaccination history were obtained through interview of the patient or close relative and review of written medical information. The validity of the patient self-report was compared to the written medical information by calculation of the sensitivity, specificity, concordance, positive predictive value (PPV) and negative predictive value (NPV). A total of 2484 patients were initially included of whom 1814 patients (73%) responded about their vaccination status. The global sensitivity of the patient self-report was 0.74 and the specificity 0.95. The PPV was 0.92, the NPV 0.84 and the concordance 87. Vaccination cards and centralized vaccination registries in primary health care centres and hospitals should be potentiated in order to ensure that neither more nor less vaccinations are administered than are necessary.

Clinical impact of imipenem-resistant Pseudomonas aeruginosa bloodstream infections.

OBJECTIVES: To describe the incidence and clinical characteristics of imipenem-resistant (IR) Pseudomonas aeruginosa bacteraemia. METHODS: We performed a retrospective study including all episodes of IR P. aeruginosa bacteraemia seen from January 2003 to December 2005 in a tertiary teaching hospital. RESULTS: There were 108 episodes of IR P. aeruginosa bacteraemia, which represented an incidence of 0.14 episodes per 1000 patient-days in 2003 and 0.11 episodes per 1000 patient-days in 2005. 83 of the episodes (77%) were nosocomially acquired. Most of patients had at least one underlying disease and had previously received antimicrobial treatment. The most frequent source was the urinary tract (31%), followed by unknown origin (22%). A total of 23 (21%) episodes were polymicrobial and 51 (47%) were caused by multidrug-resistant strains. The independent risk factors for mortality from IR P. aeruginosa bloodstream infection were a high-risk source of the bacteraemia (OR: 4.6; 95% CI 1.7-12.4; p=0.01), and presentation with severe sepsis (OR: 2.8; 95% CI 1-7.8; p=0.05). CONCLUSIONS: Our study shows that the rates of IR P. aeruginosa bacteraemia remained stable throughout the study period. The source of bacteraemia and the clinical presentation with severe sepsis were the main determinants of the prognosis.

[Impact and control of methicillin-resistant Staphylococcus aureus (MRSA) in long-term care facilities]. / Impacto y control de Staphylococcus aureus resistente a la meticilina (SARM) en los centros de larga estancia.

Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are a growing concern in long-term care facilities (LTCF). Epidemiologic studies performed in our area have shown high rates of MRSA colonization in elderly residents, and very high rates in some centres. However, the clinical impact of nasal MRSA colonization is often slight. Prevention of MRSA transmission in LTCF includes the application of simple preventive measures with proven effectiveness, such as hand washing, adequately covering of infected wounds, and proper use of antibiotics, without limiting the activities of colonized residents or carrying out active surveillance.

Nosocomial outbreak due to extended-spectrum-beta-lactamase- producing Enterobacter cloacae in a cardiothoracic intensive care unit.

Enterobacter cloacae has been associated with several outbreaks, usually involving strains that overproduce chromosomal beta-lactamase or, uncommonly, strains expressing extended-spectrum beta-lactamases (ESBL). Only sporadic cases of ESBL-producing E. cloacae have been identified in our hospital in recent years. We describe the epidemiology and clinical and microbiological characteristics of an outbreak caused by ESBL-producing E. cloacae in a cardiothoracic intensive care unit (CT-ICU). Prospective surveillance of patients with infection or colonization by ESBL-producing E. cloacae among patients admitted to the CT-ICU was performed during the outbreak. Production of ESBL was determined by decreased susceptibility to expanded-spectrum cephalosporins and a positive double-disk test result. Clone relatedness was determined by pulsed-field gel electrophoresis (PFGE). From July to September 2005, seven patients in the CT-ICU with ESBL-producing E. cloacae were identified (four males; median age, 73 years; range, 45 to 76 years); six patients had cardiac surgery. Four patients developed infections; three had primary bacteremia, one had ventilator-associated pneumonia, and one had tracheobronchitis. ESBL-producing E. cloacae showed resistance to quinolones and aminoglycosides. PFGE revealed two patterns. Five isolates belonged to clone A; two carried a single ESBL (pI 8.2 and a positive PCR result for the SHV type), and three carried two ESBLs (pIs 8.1 and 8.2 and positive PCR results for the SHV and CTX-M-9 types). Isolates belonging to clone B carried a single ESBL (pI 5.4 and a positive PCR result for the TEM type). Review of antibiotic consumption showed increased use of cefepime and quinolones during June and July 2005. The outbreak was stopped by the implementation of barrier measures and cephalosporin restriction. ESBL production could be increasingly common in nosocomial pathogens other than Escherichia coli or Klebsiella pneumoniae.