Association between antibiotic pressure and the risk of colonization/infection by multidrug-resistant Acinetobacter baumannii complex: a time series analysis.

OBJECTIVE: To analyze the association between antibiotic pressure and the risk of colonization/infection by Acinetobacter baumannii complex (AB), evaluating both the individual and general prescriptions of antibiotics. METHODS: This is an analytical, observational, case-control study on patients admitted to an Intensive Care Unit (ICU) during an AB outbreak (14 months). A five-year time series was constructed with the monthly incidence of cases of infection/colonization with strains of AB resistant to each antibiotic administered and with the monthly consumption of these antibiotics in the ICU. RESULTS: We identified 40 patients either infected (23) or colonized (17) by AB and 73 controls. We found an epidemic multidrug-resistant clone of AB in 75% of cases. Risk factors associated with the development of AB infection/colonization were: greater use of medical instruments, the presence of a tracheostomy, cutaneous ulcers, surgical lesions and prior antibiotic therapies. The regression analysis of individual use of antibiotics showed that prior treatment with ceftazidime, ceftriaxone, amoxicillin/clavulanate, imipenem, levofloxacin, linezolid, and vancomycin was a risk factor for acquiring AB. ARIMA models showed that the relationship were greatest and statistically significant when the treatment occurred between 6 months (ceftazidime) and 9 months (imipenem and levofloxacin) prior. CONCLUSIONS: The dynamic and aggregate relationship between the incidence of infection/colonization by multidrug-resistant strains of AB and prior antibiotic treatment was statistically significant for intervals of 6 to 9 months.

[Economic evaluation of the Alfred 60/AST device implantation for bacterial growth detection with automatic sewing machine]. / Evaluación económica de la implantación del autoanalizador Alfred 60/AST de detección de crecimiento bacteriano con sembrador automático.

OBJECTIVE: It is becoming increasingly necessary to automatize screening of urine samples to culture at Microbiology laboratories. Our objective was to estimate the budget threshold from which the Alfred 60/AST device would be profitable for our hospital. METHODS: Cost minimization study by decision trees, carried out in a General Hospital. The cost of traditional urine culture and urine processing using Alfred-60/AST were compared. Traditional processing involves the culture of all urine specimens received onto blood and MacConkey agar, and identification of every microorganism isolated by Vitek-2 system. The autoanalyzer would only inoculate the positive urines onto a chromogenic media, directly identifying the Escherichia coli isolates. RESULTS: The variables with the greatest economic impact in the model were the probability of obtaining a positive culture, the prevalence of E. coli in the urine cultures and the cost per sample using Alfred-60/AST. The multivariate sensitivity analysis showed that the model was solid. The bivariate sensitivity analysis showed that the model is suceptible to cost modification, mainly of the automatic device. At a threshold value of 1.40 euros/determination, the automatic processing would decrease the annual costs in 2,879 euros. CONCLUSIONS: The introduction of the Alfred-60/AST device in our laboratory at 1.40 euros/determination would reduce urine processing workload, saving time and costs.

Approach of clinicians to candiduria and related outcome in the elderly.

OBJECTIVE: Candiduria is increasingly frequent in hospitalized debilitated patients. We aimed to evaluate the approach of clinicians to candiduria in the oldest old, and its effect on clearance and mortality. MATERIAL AND METHODS: An observational study without intervention was carried out during 2012 and 2013 in three Spanish hospitals over patients with nosocomial candiduria aged 80 and over. Following a diagnostic algorithm, we assessed the appropriateness of antifungal therapy and analyzed the impact of the clinical approach (antifungal therapy, antibiotics discontinuation and catheter removal or replacement) on the outcome (mortality at 60 days and resolution, persistence or recurrence of candiduria). RESULTS: Hundred and forty eight patients were included. Symptomatology was attributable to candiduria in 31 instances and 19 asymptomatic patients were found at risk of developing candidemia. In response to culture-results, 77 (52%) of patients were treated with antifungals, mainly fluconazole (97.4%). The use of pharmacological therapy was appropriate (P<0.05) but subtherapeutical doses of fluconazole were widely used and follow-up samples were scarcely submitted. At 60 days of diagnosis the mortality was high (29.7%). The replacement or removal of the catheter resulted in a decrease in mortality and the use of antifungal treatment was associated with recurrence (P<0.05). CONCLUSIONS: In the absence of clinical practice guidelines with enough evidence, our study suggests that catheter removal should always be tried in the elderly with candiduria, since it reduces the mortality. The repetition of culture should help to better characterize the asymptomatic episodes, which are predominant, and to reduce the use of antifungals.

[Monoclonal spread of multi-drug resistant CTX-M-15-producing Klebsiella pneumoniae. Impact of measures to control the outbreak]. / Diseminación monoclonal de Klebsiella pneumoniae productora de CTX-M-15 multirresistente. Impacto de las medidas para controlar el brote.

OBJECTIVE: To describe an outbreak of multi-drug resistant extended-spectrum ß-lactamases-producing Klebsiella pneumoniae (MDR-ESBL-KPN) and the impact of measures for its control. METHODS: We reviewed the patients´ clinical records with MDR-ESBL-KPN isolation during 2013-2016 with resistance to fluoroquinolones, aminoglycosides, fosfomycin, and nitrofurantoin; susceptible to imipenem, meropenem, colistin, and tigecycline and variable to ertapenem and cotrimoxazole (Vitek-2). The genetic relationship between 35 isolates was established by PFGE and MLST. Control measures were put in place in January 2016. RESULTS: We detected 269 patients colonized and/or infected by KPN-ESBL-MDR with a common resistance phenotype; the strains studied carried the blaCTX-M-15 gene and formed a single cluster belonging to ST11. The outbreak was detected at the end of 2015, although it began in 2013 in an elderly center. The acquisition source of the strains was: 6% community-acquired, 37% hospital-acquired (76% in internal medicine) and 57% related to long health care facilities (78% of hospitalizations in the last year). Ninety-four percent of patients had at least one underlying disease, 90% received antibiotics previously and 49% had some invasive devices. After the introduction of control measures, the incidence of cases in the quarter was reduced from 29 to 15. CONCLUSIONS: We detected a monoclonal outbreak of MDR-CTX-M-15-KPN in 2015, with predominance of health-care associated cases. The success in the rapid spread of the outbreak was due to the delay in its detection and to the fact that most of the patients had previously received antibiotics. The control measures reduced the number of isolates by 50%.

[Results of the implementation of an Antimicrobial Stewardship Program in the "Gerencia de Atención Integrada" of Alcazar de San Juan (Castilla La Mancha)]. / Resultados de la implantación de un Programa de Optimización de Antimicrobianos en la Gerencia de Atención Integrada de Alcázar de San Juan (Castilla La Mancha).

OBJECTIVE: Our aim was to evaluate the efficiency of an ASP after its implementation in 2016 in a Spanish hospital quality system. METHODS: Efficiency of the ASP was measured by process and outcome indicators at the level of the patient's quality of life, antimicrobial consumption and percentage of resistance to them during the 2016-2017 period. In 2017, the failures mode and effects analysis (FMEA) methodology was applied. An annual satisfaction survey was conducted. RESULTS: The clinical indicators were within the threshold of acceptability, as well as the empirical prescription of antimicrobials, the consumption of antibiotics (reduction of 77 DDD in the first semester of 2016 to 26 in the second semester of 2017) and the renal (gentamicin) and neurological (carbapenems) toxicity. The FMEA identified as a main risk the lack of adequacy of the empirical treatment once the antibiogram was obtained; thus, a corrective action was taken in 2017. Regarding the microbiological indicators, the incidence of multi-drug resistant and carbapenemase-producing enterobacteria, and that of methicillin-resistant Staphylococcus aureus, were reduced. Eighty-three percent of the counselling activities carried out were accepted. The surveys revealed a good acceptance and spread of the program, the need for protocols and training in the use of antibiotics. CONCLUSIONS: The implementation of the ASP in the quality system was efficient. The consumption of antibiotics and the adverse effects derived from their use were reduced, improving the quality of life of patients, and reducing health costs.

[Clinical significance and risk factors for multidrug resistant Enterobacteriaceae colonization]. / Factores de riesgo de colonización por enterobacterias multirresistentes e impacto clínico.

OBJECTIVE: To identify the main risk factors of rectal colonization by multidrug resistant Enterobacteriaceae (MRE), and their clinical impact. METHODS: An observational, prospective cohort study was carried out, between April 2016 and June 2017, where every Monday of each week rectal samples were taken from all the patients admitted at that moment in the Intensive Care Unit. We performed a descriptive analysis of all the variables collected during the study and a multivariate logistic regression analysis to determine the independent association of carriers of MRE against non-carriers and several possible risk factors. RESULTS: During the study period, rectal samples were collected from 208 patients. Of the 208, 30 were carriers of MRE, with a mean age of 64.3 years and a mean score of APACHE II (Acute Physiology and Chronic Health Evaluation II) of 20.6 points. 70% of the patients with MRE had a positive result in the first rectal sample. The variables that were associated with an increased risk of rectal colonization by EMR in the regression analysis were the administration of antibiotics in the previous month (OR 5.2, 95% CI 1.71-15.79) and post-surgical patients (OR 3.8; IC95% 1.51 - 9.51). Although patients with EMR had more frequent infections by these bacteria, no differences were observed in mortality between the two groups. CONCLUSIONS: Post-surgical patients admitted to the ICU and those who received antibiotic treatment in the previous month have a higher probability of colonization due to MRE. The colonized patients presented more frequent infections by MRE although it was not associated to a higher mortality.

[Pneumonia by Corynebacterium pseudodiphteriticum: an infection to consider]. / Neumonía por Corynebacterium pseudodiphteriticum: una patología a considerar.

Corynebacterium pseudodiphteriticum has been considered a very infrequent respiratory pathogen. We report three cases of pneumonia due to C. pseudodiphteriticum, describing their clinical and microbiological features. There were two patients with pre-existing chronic respiratory disease, one of their with steroidal therapy, and other associated with endotracheal intubation. The diagnostic was made by Gram stain and quantitative cultures from respiratory tract specimens. All patients were cured after treatment with amoxicillin-clavulanate, ceftriaxone and vancomycin respectively. C. pseudodiphteriticum must be consider as a possible causal agent of pneumonia in patients with underlying respiratory disease or endotracheal intubation. Antimicrobial susceptibility testing of C. pseudodiphteriticum may be useful for correct treatment of infected patients, but beta-lactam antibiotics are an appropriate therapeutic option against this bacteria.

Bacteriemia neonatal por Streptococcus bovis / Neonatal bacteremia caused by Streptococcus bovis

Streptococcus bovis es una causa reconocida de bacteriemia y endocarditis en adultos, habitualmente en asociación con enfermedades gastrointestinales. Por el contrario, este microrganismo es una causa muy infrecuente de enfermedad infecciosa neonatal y pediátrica. Se presentan dos casos de infección neonatal con aislamiento de S. bovis (biotipo 11/2) en sangre.El primer paciente debutó con fiebre y sintomatología gastrointestinal y se recuperó de forma favorable tras el tratamiento antibiótico. El segundo paciente padeció distrés respiratorio, su evolución fue fulminante y murió a las 22 horas de vida apesar del tratamiento. En la revisión efectuada de la bibliografía comprobamos que se han comunicado con anterioridad 27 casos de infección neonatal con aislamiento de S. bovis en sangre. En esta revisión, la infección se asocia con un relativo buen pronóstico pero, de forma excepcional, como ocurrió en el segundo paciente, la evolución puede ser fulminante y rápidamente mortal

Streptococcus bovis is a recognized cause of bacteremia and endocarditis in adults, usually in association with gastrointestinal diseases. In contrast, this microorganism is a very infrequent cause of neonatal and pediatric infectious diseases. Were port two cases of neonatal infection in which S. bovis (biotype 11/2) was isolated from blood. The first patient presented with fever and gastrointestinal symptoms and recovered after antibiotic treatment. The second patient presented with respiratory distress. His course was fulminant and, in spite of therapy, he died 22 hours after birth. A review of the literature revealed only 27 previously reported cases of neonatal infectiondue to S. bovis in which this microorganism was isolated from blood. In this review, the infection appeared to be associated with a relatively good prognosis, but occasionally, as in the case of our second patient, the course can be rapid and fulminant and the outcome fatal

Neumonía por Corynebacterium pseudodiphteriticum: una patología a considerar / Pneumonia by Corynebacterium pseudodiphteriticum to consider

Corynebacterium pseudodiphteriticum es considerado un patógeno respiratorio muy infrecuente. Presentamos 3 casos de neumonía atribuibles a C. pseudodiphteriticum, describiendo sus características clínicas y microbiológicas. En los dos primeros casos existía enfermedad respiratoria crónica previa, además de corticoterapia asociada en uno de ellos, y en el caso restante tan solo maniobras repetidas de intubación endotraqueal. El diagnóstico se orientó por la tinción de Gram, confirmándose con cultivos cuantitativos de muestras respiratorias. La evolución fue favorable en los 3 casos, tras tratamiento con amoxicilina-clavulánico, ceftriaxona y vancomicina respectivamente. C. pseudodiphteriticum debe ser tenido en cuenta como posible agente causal de neumonías, sobre todo en pacientes con patología respiratoria subyacente o sometidos a intubación endotraqueal. El tratamiento debe ajustarse al patrón de susceptibilidad a antimicrobianos, aunque los betalactámicos parecen ser la opción más adecuada

Corynebacterium pseudodiphteriticum has been considered a very infrequent respiratory pathogen. We report three cases of pneumonia due to C. pseudodiphteriticum, describing their clinical and microbiological features. There were two patients with pre-existing chronic respiratory disease, one of their with steroidal therapy, and other associated with endotracheal intubation. The diagnostic was made by Gram stain and quantitative cultures from respiratory tract specimens. All patients were cured after treatment with amoxicillin-clavulanate, ceftriaxone and vancomycin respectively. C. pseudodiphteriticum must be consider as a possible causal agent of pneumonia in patients with underlying respiratory disease or endotracheal intubation. Antimicrobial susceptibility testing of C. pseudodiphteriticum may be useful for correct treatment of infected patients, but beta-lactam antibiotics are an appropriate therapeutic option against this bacteria

Peritonitis bacteriana espontánea por Listeria monocytogenes. A propósito de un nuevo caso / Spontaneous bacterial peritonitis caused by Listeria monocytogenes. Review of one case

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Bacteriemia por Neisseria subflava biovar flava / Bacteremia due to Neisseria subflava

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