Real-time monitoring of biofilm growth identifies andrographolide as a potent antifungal compound eradicating Candida biofilms.

Candida species cause life-threatening infections with high morbidity and mortality rates and their resistance to conventional therapy is closely linked to biofilm formation. Thus, the development of new approaches to study Candida biofilms and the identification of novel therapeutic strategies could yield improved clinical outcomes. In the current study, we have set up an impedance-based in vitro system to study Candida spp. biofilms in real-time and to evaluate their sensitivity to two conventional antifungal groups used in clinical practice - azoles and echinocandins. Both fluconazole and voriconazole were unable to inhibit biofilm formation in most strains tested, while echinocandins showed biofilm inhibitory capacity at relatively low concentrations (starting from 0.625 mg/L). However, assays performed on 24 h Candida albicans and C. glabrata biofilms revealed that micafungin and caspofungin failed to eradicate mature biofilms at all tested concentrations, evidencing that once formed, Candida spp. biofilms are extremely difficult to eliminate using currently available antifungals. We then evaluated the antifungal and anti-biofilm effect of andrographolide, a natural compound isolated from the plant Andrographis paniculata with known antibiofilm activity on Gram-positive and Gram-negative bacteria. Optical density measures, impedance evaluation, CFU counts, and electron microscopy data showed that andrographolide strongly inhibits planktonic Candida spp. growth and halts Candida spp. biofilm formation in a dose-dependent manner in all tested strains. Moreover, andrographolide was capable of eliminating mature biofilms and viable cell numbers by up to 99.9% in the C. albicans and C. glabrata strains tested, suggesting its potential as a new approach to treat multi-resistant Candida spp. biofilm-related infections.

Bacteraemia and quick Sepsis Related Organ Failure Assessment (qSOFA) are independent risk factors for long-term mortality in very elderly patients with suspected infection: retrospective cohort study.

BACKGROUND: In older adult patients, bloodstream infections cause significant mortality. However, data on long-term prognosis in very elderly patients are scarce. This study aims to assess 1-year mortality from bacteraemia in very elderly patients. METHODS: Retrospective cohort study in inpatients aged 80 years or older and suspected of having sepsis. Patients with (n = 336) and without (n = 336) confirmed bacteraemia were matched for age, sex, and date of culture, and their characteristics were compared. All-cause mortality and risk of death were assessed using the adjusted hazard ratio (aHR). RESULTS: Compared to controls, cases showed a higher 1-year mortality (34.8% vs. 45.2%) and mortality rate (0.46 vs. 0.69 deaths per person-year). Multivariable analysis showed significant risk of 1-year mortality in patients with bacteraemia (aHR: 1.31, 95% confidence interval [CI] 1.03-1.67), quick Sepsis Related Organ Failure Assessment (qSOFA) score of 2 or more (aHR: 2.71, 95% CI 2.05-3.57), and age of 90 years or older (aHR 1.53, 95% CI 1.17-1.99). CONCLUSIONS: In elderly patients suspected of sepsis, bacteraemia is associated with a poor prognosis and higher long-term mortality. Other factors related to excess mortality were age over 90 years and a qSOFA score of 2 or more.

Real-time monitoring of Pseudomonas aeruginosa biofilm growth dynamics and persister cells' eradication.

Biofilm formation and the appearance of persister cells with low metabolic rates are key factors affecting conventional treatment failure and antibiotic resistance. Using impedance-based measurements, crystal violet staining and traditional culture we have studied the biofilm growth dynamics of 13 Pseudomonas aeruginosa strains under the effect of seven conventional antibiotics. Real-time growth quantifications revealed that the exposure of established P. aeruginosa biofilms to certain concentrations of ciprofloxacin, ceftazidime and tobramycin induced the emergence of persister cells, that showed different morphology and pigmentation, as well increased antibiotic resistance. Whole-genome sequencing of wildtype and persister cells identified several SNPs, a genomic inversion and a genomic duplication in one of the strains. However, these mutations were not uniquely associated with persisters, suggesting that the persistent phenotype may be related to metabolic and transcriptional changes. Given that mannitol has been proposed to activate bacterial metabolism, the synergistic combination of mannitol and ciprofloxacin was evaluated on clinical 48 h P. aeruginosa biofilms. When administered at doses ≥320 mg/L, mannitol was capable of preventing persister cell formation by efficiently activating dormant bacteria and making them susceptible to the antibiotic. These results were confirmed using viable colony counting. As the tested ciprofloxacin-mannitol combination appeared to fully eradicate mature biofilms, we conclude that impedance-based biofilm diagnostics, which permits antibiotic susceptibility testing and the identification of persister cells, is of great potential for the clinical practice and could aid in establishing treatment breakpoints for emerging biofilm-related infections.

Effectivity of a Program for the Control and Prevention of COVID-19 Healthcare-Associated Infections in a Spanish Academic Hospital.

BACKGROUND: Although recommendations to prevent COVID-19 healthcare-associated infections (HAIs) have been proposed, data on their effectivity are currently limited. OBJECTIVE: The aim was to evaluate the effectivity of a program of control and prevention of COVID-19 in an academic general hospital in Spain. METHODS: We captured the number of COVID-19 cases and the type of contact that occurred in hospitalized patients and healthcare personnel (HCP). To evaluate the impact of the continuous use of a surgical mask among HCP, the number of patients with COVID-19 HAIs and accumulated incidence of HCP with COVID-19 was compared between the preintervention and intervention periods. RESULTS: Two hundred fifty-two patients with COVID-19 have been admitted to the hospital. Seven of them had an HAI origin (6 in the preintervention period and 1 in the intervention period). One hundred forty-two HCP were infected with SARS-CoV-2. Of them, 22 (15.5%) were attributed to healthcare (2 in the emergency department and none in the critical care departments), and 120 (84.5%) were attributed to social relations in the workplace or during their non-work-related personal interactions. The accumulated incidence during the preintervention period was 22.3 for every 1000 HCP and 8.2 for every 1000 HCP during the intervention period. The relative risk was 0.37 (95% confidence interval, 0.25 to 0.55) and the attributable risk was -0.014 (95% confidence interval, -0.020 to -0.009). CONCLUSIONS: A program of control and prevention of HAIs complemented with the recommendation for the continuous use of a surgical mask in the workplace and social environments of HCP effectively decreased the risk of COVID-19 HAIs in admitted patients and HCP.

Frequency, Associated Risk Factors, and Characteristics of COVID-19 Among Healthcare Personnel in a Spanish Health Department.

INTRODUCTION: This study examines the frequency, associated factors, and characteristics of healthcare personnel coronavirus disease 2019 cases in a healthcare department that comprises a tertiary hospital and its associated 12 primary healthcare centers. METHODS: This study included healthcare personnel that showed symptoms or were in contact with a coronavirus disease 2019 case patient from March 2, 2020 to April 19, 2020. Their evolution and characteristics (age, sex, professional category, type of contact) were recorded. Correlations between the different characteristics and risk of developing coronavirus disease 2019 and severe coronavirus disease 2019 were analyzed using chi-square tests. Their magnitudes were quantified with ORs, AORs, and their 95% CIs using a logistic regression model. RESULTS: Of the 3,900 healthcare professionals in the department, 1,791 (45.9%) showed symptoms or were part of a contact tracing study. The prevalence of those with symptoms was 20.1% (784/3,900; 95% CI=18.8, 21.4), with coronavirus disease 2019 was 4.0% (156/3,900; 95% CI=3.4, 4.6), and with severe coronavirus disease 2019 was 0.5% (18/3,900; 95% CI=0.2, 0.7). The frequency of coronavirus disease 2019 in symptomatic healthcare personnel with a nonprotected exposure was 22.8% (112/491) and 13.7% (40/293) in those with a protected exposure (AOR=2.2, 95% CI=1.2, 3.9). The service in which the healthcare personnel performed their activity was not significantly associated with being diagnosed with coronavirus disease 2019. A total of 26.3% (10/38) of male healthcare personnel with coronavirus disease 2019 required hospitalization, compared with 6.8% (8/118) among female healthcare personnel (OR=4.9, 95% CI=1.8, 13.6). CONCLUSIONS: A surveillance and monitoring program centred on healthcare personnel enables an understanding of the risk factors that lead to coronavirus disease 2019 among this population. This knowledge allows the refinement of the strategies for disease control and prevention in healthcare personnel during the coronavirus disease 2019 pandemic.

Effect of Dalbavancin on Staphylococcal Biofilms When Administered Alone or in Combination With Biofilm-Detaching Compounds.

Microorganisms grown in biofilms are more resistant to antimicrobial treatment and immune system attacks compared to their planktonic forms. In fact, infections caused by biofilm-forming Staphylococcus aureus and Staphylococcus epidermidis are a large threat for public health, including patients with medical devices. The aim of the current manuscript was to test the effect of dalbavancin, a recently developed lipoglycopeptide antibiotic, alone or in combination with compounds contributing to bacterial cell disaggregation, on staphylococcal biofilm formation and elimination. We used real-time impedance measurements in microtiter plates to study biofilm growth dynamics of S. aureus and S. epidermidis strains, in the absence or presence of dalbavancin, linezolid, vancomycin, cloxacillin, and rifampicin. Further experiments were undertaken to check whether biofilm-detaching compounds such as N-acetylcysteine (NAC) and ficin could enhance dalbavancin efficiency. Real-time dose-response experiments showed that dalbavancin is a highly effective antimicrobial, preventing staphylococcal biofilm formation at low concentrations. Minimum biofilm inhibitory concentrations were up to 22 higher compared to standard E-test values. Dalbavancin was the only antimicrobial that could halt new biofilm formation on established biofilms compared to the other four antibiotics. The addition of NAC decreased dalbavancin efficacy while the combination of dalbavancin with ficin was more efficient than antibiotic alone in preventing growth once the biofilm was established. Results were confirmed by classical biofilm quantification methods such as crystal violet (CV) staining and viable colony counting. Thus, our data support the use of dalbavancin as a promising antimicrobial to treat biofilm-related infections. Our data also highlight that synergistic and antagonistic effects between antibiotics and biofilm-detaching compounds should be carefully tested in order to achieve an efficient treatment that could prevent both biofilm formation and disruption.

The quick Sepsis-related Organ Failure Assessment (qSOFA) is a good predictor of in-hospital mortality in very elderly patients with bloodstream infections: A retrospective observational study.

People over 80 years old are now the fastest-growing age group. Bloodstream infections (BSI) in these patients may present with specific characteristics. The objective of this study was to analyze independent factors affecting in-hospital mortality (IHM) due to BSI in very elderly patients (≥80 years of age) and to compare the clinical presentation of BSI in patients aged 80-89 years versus those aged 90 or more. Retrospective, cross-sectional and observational study of BSI in patients aged 80 years or older. The study used IHM as the primary outcome. Stepwise multiple logistic regression models were used to identify associations between potential predictors and IHM. Of the 336 included patients, 76.8% (n = 258) were in the 80-89-year age group and 23.2% (n = 78) in the 90+ age group; 17.3% (n = 58) of patients died during admission. This outcome was independently associated with quick Sepsis Related Organ Failure Assessment (qSOFA) of 2 or more (adjusted odds ratio [aOR] 4.7, 95% confidence interval [CI] 2.3-9.4; p < 0.001). Other predictors included an origin of BSI outside the urinary tract (aOR 5.5, 95% CI 2.4-12.6; p < 0.001), thrombocytopenia (aOR 4.9, 95% CI 1.8-13.4; p = 0.002), hospital-acquired infection (aOR 3.0, 95% CI 1.2-7.5; p = 0.015), and inappropriate empiric antibiotics (aOR 2.0, 95% CI 1.1-3.9; p = 0.04). IHM was 23.1% in the 90+ age group and 15.5% in patients aged 80 to 89 (p = 0.012). However, the 90+ age group was more likely to have a score of at least 2 on the qSOFA (29.9% vs. 19.1%, p = 0.043) and Pitt bacteremia scales (44.9% vs. 30.2%; p = 0.02), as well as chronic kidney disease (56.4% vs. 36.0%; p = 0.001) and altered mental state (40.3% vs. 25.7%; p = 0.013). In conclusion: A qSOFA score of 2 or more and a BSI originating outside the urinary tract were independent predictors of IHM. The 90+ age group was at higher risk than the 80-89-year age group of having a qSOFA score and Pitt bacteremia score of 2 or more as well as an altered mental state.

Organización y métodos didácticos de una asignatura que integra asignaturas y competencias transversales en el Grado en Medicina. Experiencia con «Talleres integrados II» de la Universidad Miguel Hernández de Elche / Organisation and didactic methods of a subject that integrates subjects and transversal skills into the Medical Degree. Experience with the Integrated Workshops of the Miguel Hernández University of Elche, Spain

Los estudiantes de medicina necesitan adquirir una serie de conocimientos, habilidades y actitudes que les capaciten para el desempeño de la medicina. La facultad de Medicina de la Universidad Miguel Hernández de Elche incluyó en su plan de estudios del Grado en Medicina 4 asignaturas denominadas «talleres integrados» en las que se desarrollan diversas actividades docentes para integrar conocimientos y habilidades clínicas de varias disciplinas y fomentar la adquisición de competencias transversales. En este artículo describimos la organización y métodos didácticos empleados en la asignatura «Talleres integrados II» como un elemento de reflexión para compartir la experiencia con la comunidad educativa en medicina. Esta asignatura integra las siguientes materias: bases generales de la cirugía, farmacología clínica, patología general, inmunología y alergia, dermatología, epidemiología y demografía sanitaria, microbiología, obstetricia y oftalmología. Es una asignatura con 4,5 créditos prácticos y utiliza elementos docentes como práctica hospitalaria guiada por objetivos, participación de alumnos y talleres prácticos, simulación, prueba evaluación de competencias objetiva estructurada, y presentación clínica en formato Pecha Kucha, lo que potencia la integración de conocimientos y el aprendizaje activo con adquisición de competencias y habilidades prácticas muy pertinentes para el futuro médico

Medical students need to acquire a range of knowledge, skills, and attitudes that will prepare them for medical clinical practice. The School of Medicine of Miguel Hernández University (Elche, Spain) includes, in its Medical Degree curriculum, 4 subjects called "Talleres integrados" (Integrated Workshops-II). Diverse teaching activities are developed to integrate knowledge and clinical skills of several disciplines, and to promote the acquisition of transversal skills. A description is presented of the organisation and didactic methods used in the Integrated Workshops-II subject as an element for reflection and to share the experience with the educational community in medicine. This subject integrates the following: general bases of surgery, clinical pharmacology, general pathology, immunology and allergy, dermatology, epidemiology and health demography, microbiology, obstetrics and ophthalmology. It is a subject with 4.5 practical credits and uses teaching elements such as hospital practice guided by objectives, student participation and practical workshops, simulation, objective structured clinical examination (OSCE), and presentation of cases in Pecha Kucha format, all of which enhances the integration of knowledge and active learning with acquisition of skills and practical skills very pertinent for the future doctor

Seasonal influenza in octogenarians and nonagenarians admitted to a general hospital: epidemiology, clinical presentation and prognostic factors / Gripe estacional en octogenarios y nonagenarios ingresados en un hospital general: epidemiología, clínica y factores pronósticos

Background. Seasonal influenza is responsible for high annual morbidity and mortality worldwide, especially in elderly patients. The aim of the study was to analyse the epidemiological, clinical and prognostic features of influenza in octogenarians and nonagenarians admitted to a general hospital, as well as risk factors associated with mortality. Methods. Retrospective, cross-sectional, descriptive study in patients admitted and diagnosed with influenza by molecular biology in the General University Hospital of Alicante from 1 January to 31 April 2015. Results. A total of 219 patients were diagnosed with influenza in the study period: 55 (25.1%) were ≤64 years-old; 77 (35.2%) were aged 65-79; 67 (30.6%) were aged 80-89 years; and 20 (9.1%) were aged ≥90 years. Most flu episodes were caused by influenza A (n=181, 82.6%). Patients aged 80 years or older had lower glomerular filtration rate (mean: 49.7 mL/min vs. 62.2 mL/min; p=0.006), a greater need for non-invasive mechanical ventilation (22% vs 9.3%; p=0.02), greater co-morbidity due to cardiac insufficiency (40.5% vs. 16.4%; p<0.001) and chronic renal disease (32.9 vs. 20%, p=0.03), and greater mortality (19% vs. 2.9%; p<0.001). In a multivariate analysis, mortality was higher in those aged 80 or over (adjusted odds ratio [ORa] 9.2, 95% confidence interval [CI] 1.65-51.1), those who had acquired the flu in a longterm care facility (ORa 11.9, 95% CI 1.06-134), and those with hyperlactataemia (ORa 1.89, 95% CI 1.20-3.00). Conclusions. Seasonal influenza is a serious problem leading to elevated mortality in octogenarian and nonagenarian patients admitted to a general hospital (AU)

Introducción. La gripe epidémica estacional es responsable de una elevada morbi-mortalidad cada año en el mundo especialmente en pacientes de edad avanzada. El objetivo del estudio fue presentar las características epidemiológicas, clínicas y pronósticas de la gripe estacional en octogenarios y nonagenarios ingresados en un hospital general y analizar los factores asociados con la mortalidad. Material y métodos. Estudio descriptivo transversal retrospectivo de los pacientes ingresados con gripe diagnosticados por biología molecular en el Hospital General Universitario de Alicante desde el 1 de enero del 2015 hasta 31 de abril del 2015. Resultados. En el periodo de estudio fueron diagnosticados 219 pacientes, de ellos 55 (25,1%) eran ≤64 años, 77 (35,2%) adultos de entre 65 y 79 años, 67 (30,6%) entre 80-89 años y 20 (9,1%) ≥90 años. La mayoría de los episodios fueron gripe causada por influenza A (n=181; 82,6%). Los pacientes ≥ 80 años tenían unos valores medios de un filtrado glomerular inferior (media: 49,7 mL/ min vs. 62.2 mL/min; p=0,006), mayor requerimiento de ventilación mecánica no invasiva (22% vs 9,3%; p=0,02), una mayor comorbilidad por insuficiencia cardiaca (40,5% vs. 16,4%p<0,001) y enfermedad renal crónica (32,9 vs. 20%, p=0,03), así como mayor mortalidad (19% vs. 2,9%; p<0,001). En el análisis multivariado, la mortalidad fue superior en los mayores de 80 años (odds ratio ajustada [ORa]: 9,2, intervalo de confianza [IC] del 95%: 1,65-51,1), con adquisición de la gripe en un centro socio sanitarios (ORa: 11,9, IC 95%: 1,06-134) y la hiperlactacidemia (ORa: 1,89, IC 95%: 1,20-3,00). Conclusiones. La gripe es un grave problema con elevada mortalidad en pacientes octogenarios y nonagenarios ingresados en un hospital general (AU)

Serological study of Trypanosoma cruzi, Strongyloides stercoralis, HIV, human T cell lymphotropic virus (HTLV) and syphilis infections in asymptomatic Latin-American immigrants in Spain.

OBJECTIVE: We aimed to perform a serological screening for T. cruzi, Strongyloides stercoralis, HIV, human T cell lymphotropic virus (HTLV) and syphilis in Latin American immigrants admitted to hospital in Spain. METHODS: We have carried out a cross-sectional study of Latin American immigrants admitted to the Hospital General Universitario Alicante (Spain) from June 2012 to May 2014, where screening of Chagas disease, strongyloidiasis, HTLV, HIV and syphilis was performed by serology. RESULTS: A total 180 patients were included in the study. Patients' median age was 38 years old, 123 (68.3%; 123/180) were female and 57 (31.7%; 57/180) male. Five of the 180 (2.5%) patients were positive for Chagas disease; associated with knowledge about Chagas disease (p=0.005), previous contact with patients with Chagas disease (p=0.04) and being Bolivian (p<0.001). Forty-two of the 157 (26.8%) patients were positive for Strongyloides serology; associated positively with being male (p<0.001), eosinophilia (p=0.001), hyper-IgE (p<0.001) and being Ecuadorian (p=0.001), and negatively associated with being Colombian (p=0.03). Positive serology of latent syphilis was found in 1.8% (3/171) of patients. Serology of HTLV was negative in all cases. No new cases of HIV infection were diagnosed. CONCLUSIONS: We propose that Latin American immigrant patients admitted to hospital in Spain be screened for strongyloidiasis, Chagas disease and syphilis by serology.

Seroprevalence of HTLV-1/2 infection among native and immigrant pregnant women in Spain.

HTLV-1=2 antenatal screening is not mandatory in European countries. The rapid increase in immigrants coming from areas endemic for HTLV-1 infection has compelled a review of this policy in Spain. From February 2006 to December 2007, a cross-sectional study was carried out in all pregnant women attended at 10 different Spanish hospitals. An enzyme immunoassay (EIA) was used to test serum HTLV-1=2 antibodies; reactive samples were further confirmed by Western blot and=or polymerase chain reaction. A total of 20,518 pregnant women were examined, of whom 18,266 (89%) were native Spaniards. Overall, 946 (4.6%) of the immigrants came from HTLV-1 endemic areas (mainly Central and South America and sub-Saharan Africa). Four samples were EIA seroreactive for HTLV-1=2, two of them in women infected with HTLV-1 coming from endemic areas. The other two women were infected with HTLV-2; one was an immigrant from Bolivia and another was a native Spaniard who admitted prior injection drug use and was HIV-1 positive. The overall HTLV-1=2 seroprevalence was 0.19 per 1000 (95% CI: 0.05-0.49=1000). For HTLV-1, the seroprevalence was 2.11 per 1000 (95% CI: 0.26-7.62=1000) in pregnant women from endemic areas. The seroprevalence of HTLV-1=2 infection is below 0.02% among pregnant women in Spain, and therefore universal screening for HTLV-1=2 infection in antenatal clinics is not warranted. However, HTLV-1=2 screening could be considered in pregnant women coming from endemic areas, in whom the rate of infection is nearly 1000-fold higher than in native Spaniards and are the only group infected with the more pathogenic HTLV-1.

Nuevos marcadores microbiológicos de la hepatitis C / New microbiological markers of hepatitis C

Hepatitis C is a serious public health problem because it infects 2% of world population. The new microbiological tools based on molecular biology are very useful to diagnose, prevent and treat this disease. This review shows the progress in these technologies, focusing in the importance of genotypes and viral quasispecies, as well as in the importance of the study of Ag of core and RNA detection. It also deals with the utility of the secuenciation in drugs resistance detection and virus epidemiology

La hepatitis C es un importante problema de salud pública, ya que afecta al 2% de la población mundial. Las nuevas técnicas microbiológicas basadas en la biología molecular proporcionan herramientas muy útiles para mejorar el diagnóstico, la prevención y el tratamiento de esta enfermedad. En esta revisión se exponen los últimos avances de estas técnicas, haciendo hincapié en la importancia de la genotipificación de las cuasiespecies virales y de la detección viral mediante la búsqueda del antígeno del core y del ARN viral, así como en la utilidad de la secuenciación en la detección de resistencia a fármacos y en el estudio de la epidemiología del virus