Implementación del protocolo hospitalario de insulinización subcutánea para pacientes no críticos en hospitales andaluces de tercer nivel / Implementation of subcutaneous insulin protocol for non-critically ill hospitalized patients in andalusian tertiary care hospitals

INTRODUCCIÓN: En 2009, la Sociedad Andaluza de Endocrinología y Nutrición diseñó un protocolo de insulinización subcutánea para pacientes hospitalizados no críticos («Protocolo de insulinización hospitalaria para el paciente no crítico» [PIH]), adoptado dentro del Sistema Sanitario Público Andaluz. OBJETIVOS: Analizar la implementación del PIH en hospitales de tercer nivel del Sistema Sanitario Público Andaluz. MÉTODO: Estudio multicéntrico descriptivo transversal en 8 hospitales andaluces de tercer nivel, mediante muestreo aleatorizado de pacientes ingresados ≥ 48 h, con DM (n = 306), en 5 servicios médicos (SM) y 2 quirúrgicos (SQ). La DM tipo 1, DM por trastornos específicos, soporte nutricional artificial, tratamiento esteroideo y gestación fueron criterios de exclusión. RESULTADOS: Se incluyeron 288 pacientes (varones 62,5%; 70,3 ± 10,3 años; 71,5% SM y 28,5% SQ). El régimen insulínico basal-bolus-corrección se instauró en el 55,9% (IC 95%: 50,5 - 61,2%); 63,1% SM vs. 37,8% SQ (p < 0,05). Las alternativas al régimen insulínico basal-bolus-corrección fueron: pautas móviles de insulina rápida (43,7%), dieta (31,3%), antidiabéticos orales (17,2%), premezclas (1,6%) y otras (6,2%). En pacientes tratados previamente con antidiabéticos orales, la dosis de insulina durante el ingreso fue 0,32 ± 0,1 UI/kg/día. En pacientes tratados previamente con insulina, la dosis de insulina durante el ingreso se incrementó en un 17% [-13-53] y en pacientes con terapia combinada, en 26,4% [-6-100]. Las pautas correctoras empleadas para < 40UI/día y 40-80UI/día fueron las recomendadas en el 72,2% y el 56,7%, respectivamente. Se solicitó HbA1c en el 23,6% (IC 95%: 18,8-28,8); 27,7% SM vs. 13,3% SQ (p < 0,05). CONCLUSIONES: Son recomendables estrategias para aumentar la implantación del PIH, especialmente en servicios quirúrgicos. Las pautas móviles de insulina rápida son la alternativa más frecuente al régimen insulínico basal-bolus-corrección. Es preciso fomentar la valoración del control metabólico al ingreso

INTRODUCTION: In 2009, the Andalusian Society of Endocrinology and Nutrition designed a protocol for subcutaneous insulin treatment in hospitalized non-critically ill patients (HIP). OBJECTIVE: To analyze implementation of HIP at tertiary care hospitals from the Andalusian Public Health System. Method A descriptive, multicenter study conducted in 8 tertiary care hospitals on a random sample of non-critically ill patients with diabetes/hyperglycemia (n = 306) hospitalized for ≥ 48 hours in 5 non-surgical (SM) and 2 surgical (SQ) departments. Type 1 and other specific types of diabetes, pregnancy and nutritional support were exclusion criteria. RESULTS: 288 patients were included for analysis (62.5% males; 70.3 ± 10.3 years; 71.5% SM, 28.5% SQ). A scheduled subcutaneous insulin regimen based on basal-bolus-correction protocol was started in 55.9% (95% CI: 50.5-61.2%) of patients, 63.1% SM vs. 37.8% SQ (P < .05). Alternatives to insulin regimen based on basal-bolus-correction included sliding scale insulin (43.7%), diet (31.3%), oral antidiabetic drugs (17.2%), premixed insulin (1.6%), and others (6.2%). For patients previously on oral antidiabetic drugs, in-hospital insulin dose was 0.32 ± 0.1 IU/kg/day. In patients previously on insulin, in-hospital insulin dose was increased by 17% [-13-53], and in those on insulin plus oral antidiabetic drugs, in-hospital insulin dose was increased by 26.4% [-6-100]. Supplemental insulin doses used for < 40IU/day and 40-80 IU/day were 72.2% and 56.7% respectively. HbA1c was measured in 23.6% of patients (95CI%: 18.8-28.8); 27.7% SM vs. 13.3% SQ (P < .05). CONCLUSIONS: Strategies are needed to improve implementation of the inpatient subcutaneous insulin protocol, particularly in surgical departments. Sliding scale insulin is still the most common alternative to insulin regimen based on basal-bolus-correction scheduled insulin. Metabolic control assessment during hospitalization should be encouraged

Implementation of subcutaneous insulin protocol for non-critically ill hospitalized patients in andalusian tertiary care hospitals.

INTRODUCTION: In 2009, the Andalusian Society of Endocrinology and Nutrition designed a protocol for subcutaneous insulin treatment in hospitalized non-critically ill patients (HIP). OBJECTIVE: To analyze implementation of HIP at tertiary care hospitals from the Andalusian Public Health System. METHOD: A descriptive, multicenter study conducted in 8 tertiary care hospitals on a random sample of non-critically ill patients with diabetes/hyperglycemia (n=306) hospitalized for ≥48 hours in 5 non-surgical (SM) and 2 surgical (SQ) departments. Type 1 and other specific types of diabetes, pregnancy and nutritional support were exclusion criteria. RESULTS: 288 patients were included for analysis (62.5% males; 70.3±10.3 years; 71.5% SM, 28.5% SQ). A scheduled subcutaneous insulin regimen based on basal-bolus-correction protocol was started in 55.9% (95%CI: 50.5-61.2%) of patients, 63.1% SM vs. 37.8% SQ (P<.05). Alternatives to insulin regimen based on basal-bolus-correction included sliding scale insulin (43.7%), diet (31.3%), oral antidiabetic drugs (17.2%), premixed insulin (1.6%), and others (6.2%). For patients previously on oral antidiabetic drugs, in-hospital insulin dose was 0.32±0.1 IU/kg/day. In patients previously on insulin, in-hospital insulin dose was increased by 17% [-13-53], and in those on insulin plus oral antidiabetic drugs, in-hospital insulin dose was increased by 26.4% [-6-100]. Supplemental insulin doses used for<40 IU/day and 40-80 IU/day were 72.2% and 56.7% respectively. HbA1c was measured in 23.6% of patients (95CI%: 18.8-28.8); 27.7% SM vs. 13.3% SQ (P<.05). CONCLUSIONS: Strategies are needed to improve implementation of the inpatient subcutaneous insulin protocol, particularly in surgical departments. Sliding scale insulin is still the most common alternative to insulin regimen based on basal-bolus-correction scheduled insulin. Metabolic control assessment during hospitalization should be encouraged.

Comparative evaluation of three culture methods for the isolation of mycobacteria from clinical samples.

We assessed the capacity of two liquid-medium culture methods with automated incubation and reading systems (MB/BacT ALERT 3D System and BACTEC MGIT 960 System) and one solid-medium culture method (Löwenstein- Jensen) to detect mycobacteria in different types of clinical samples. Out of 1,770 cultured clinical samples (1,519 of respiratory origin and 251 of nonrespiratory origin), mycobacteria were isolated in 156 samples (135 M. tuberculosis complex, 8 M. chelonae, 6 M. kansasii, 4 M. fortuitum, 2 M. gordonae, and 1 M. marinum) by at least one of the methods used. The BACTEC MGIT 960 System proved to be the most sensitive method (86.5%), especially in the detection of M. tuberculosis complex (89.1%). However, Löwenstein- Jensen culture was the most sensitive (76.2%) to detect nontuberculous mycobacteria. The BACTEC MGIT 960 System showed the lowest mean detection time for mycobacterial growth (15.3 days), significantly shorter than the other two methods. Highest sensitivity (95.5%) and specificity (99.6%) values were obtained using the BACTEC MGIT 960 System with the Löwenstein-Jensen culture method, which was also the only combination capable of detecting 100% of the nontuberculous mycobacteria.

Activity of daptomycin against multiresistant clinical isolates of Staphylococcus aureus and Streptococcus agalactiae.

The activity of daptomycin against 141 Staphylococcus aureus and 63 Streptococcus agalactiae isolates was assessed. The isolates were previously characterized and showed resistance to the antibiotics normally used against gram-positive cocci. Daptomycin was active against 100% of the isolates (minimum inhibitory concentration [MIC(90)] = 0.5 microg/ml, for both species). This antibiotic shows good in vitro activity; therefore, it is an excellent therapeutic alternative against these isolates.

Activity in vitro of twelve antibiotics against clinical isolates of extended-spectrum beta-lactamase producing Escherichia coli.

Twelve beta-lactam and non-beta-lactam antibiotics were evaluated against 115 clinical isolates of extended-spectrum beta-lactamase-producing (ESBLs) Escherichia coli using a broth microdilution test in accordance with the CLSI guidelines. Susceptibility was 100% with imipenem, ertapenem and amikacin, 95.7% with piperacillin-tazobactam, 91.3% with cefoxitin, 87% with tobramycin, 81.7% with amoxicillin-clavulanate, 80% with cefepime, 67.8% with ceftazidime, 27.8% with ciprofloxacin, 27% with levofloxacin and 13% with ceftriaxone. Ertapenem was the antibiotic with the lowest minimum inhibitory concentrations (MICs) for all isolates. There were no clinically relevant differences in the activity of the antibiotics in the presence of CTX-M-9 or SHV enzymes.

A comparison of the activity of tigecycline against multiresistant clinical isolates of Staphylococcus aureus and Streptococcus agalactiae.

We evaluated the activity of several antibiotics against 225 clinical isolates of Staphylococcus aureus and 252 isolates of Streptococcus agalactiae. Only tigecycline, glycopeptides, and linezolid were active against all the isolates of S. aureus, whereas the beta-lactams were also active against S. agalactiae. Tigecycline could be a good alternative to ampicillin in the treatment of group B Streptococcus infections in patients allergic to beta-lactam.

High presence of extended-spectrum beta-lactamases and resistance to quinolones in clinical isolates of Escherichia coli.

A study was conducted to detect the presence of extended-spectrum beta-lactamases (ESBLs) in 706 isolates of Escherichia coli, largely from outpatients (75.2%). The Clinical and Laboratory Standards Institute (formerly NCCLS)-recommended disk diffusion procedure was used to detect ESBL presence; the VITEK 2 system (bioMérieux, Marcy L'Etoile, France) was used to determine the susceptibility to antibiotics of clinical interest, and the ESBLs were characterized by biochemical study, determining the isoelectric point, and by molecular study with PCR. Clonal distribution was studied in eight hospital isolates. There were 115 ESBL-producing isolates (16.3%), with a predominance of CTX-M9 type (58.3%). We draw attention to the high resistance to quinolones (>70%) in CTX-M9 and SHV enzyme producing isolates and the lower aminoglycoside activity in the latter.

Evaluation of two automated systems for detection of bacteriuria.

The Utiscreen-CORAL Biomedical system and ROBOBACT system were tested against conventional uroculture in blood agar and MacConkey agar as a reference method to determine the bacteriuria from 400 samples. For the Utiscreen-CORAL Biomedical system, a sensitivity of 92.5% was obtained. However, by the ROBOBACT system, the sensitivity was 69.9%.

Acceptable performance of VITEK 2 system to detect extended-spectrum beta-lactamases in clinical isolates of Escherichia coli: a comparative study of phenotypic commercial methods and NCCLS guidelines.

The disk approximation method, Etest (AB Biodisk, Solna, Sweden), and VITEK 2 system (bioMérieux, Marcy l'Etoile, France) were used to study 399 extended-spectrum beta-lactamase (ESBL)-producing (115 strains) and non-ESBL-producing (284 strains) clinical isolates of Escherichia coli after recommended procedures. Comparative study of the phenotypic findings yielded data on the sensitivity, specificity, and positive and negative predictive values and performance of each method. The sensitivity (100% using 2 substrates), specificity (99.3-100%), and predictive values of the disk approximation, Etest, and VITEK 2 methods were similar.

High incidence of extended-spectrum beta-lactamases among outpatient clinical isolates of Escherichia coli: a phenotypic assessment of NCCLS guidelines and a commercial method.

The production of extended-spectrum beta-lactamases (ESBLs) among 357 clinical isolates of Escherichia coli and 175 of Klebsiella spp. was studied using both the National Committee for Clinical Laboratory Standards disk diffusion method and the semiautomated Wider system. We highlight the predominance of E. coli (50, 92.6%) among positive samples and the largely outpatient origin of these (40, 80%), including 39 samples of urine (97.5%) and one of urethral exudate. There were only four ESBL-producing isolates of Klebsiella spp. (7.4%), and three were in outpatient urine samples (75%, 2 K. oxytoca and 1 K. pneumoniae). The positive and negative predictive values for the Wider system were 81% and 98.5%, respectively. We stress the high incidence of ESBL in our setting, the predominance of cases in the outpatient setting, and the acceptable detection of ESBL by means of the Wider system in E. coli and Klebsiella spp.

Lumbalgia en un varón de 70 años / Lumbalgia in a 70-year-old man

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Lesión cutánea edematosa y pruriginosa en antebrazo izquierdo tras un viaje a Guinea Ecuatorial / Edematous and pruriginous cutaneous lesion in the left forearm following a travel to Equatorial Guinea

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Detection of IgA and low-avidity IgG antibodies for the diagnosis of recent active toxoplasmosis.

OBJECTIVE: To determine the clinical value of testing IgA and the avidity of IgG (by two commercial systems) for the detection of recent active toxoplasmosis (RAT), and to study the IgG avidity during the course of infection. METHODS: The IgA was tested by a capture ELISA (Pasteur, France) and the avidity of IgG was determined by two modified commercial indirect ELISA methods (Sorin, Italy; Behringwerke, Germany) in 12 patients who were not immunosuppressed (group I) and 57 healthy subjects with a past infection by Toxoplasma gondii (group II). RESULTS: IgA was present in 75% of patients from group I and 21% of subjects from group II. The reliability for diagnosis of RAT was: sensitivity 75%, specificity 84%, positive predictive value 52.9% and negative predictive value 93.3%. In group I, 91.7% of patients had more than 50% low-avidity IgG, by both methods; in group II, 21% of subjects had low-avidity IgG at levels from 40% to 50%, by both methods. The diagnostic reliability of the two methods for the detection of low-avidity IgG in the first samples of RAT was similar when a breakpoint of 50% was used, with values of: sensitivity 91.7%, specificity 100%, positive predictive value 100% and negative predictive value 98%. CONCLUSIONS: The study of IgA is not on its own adequate for diagnosis of RAT. However, testing the avidity of IgG is more reliable for the diagnosis of RAT, in studies of one serum sample or sequential samples.