Neumonía nosocomial y mutirresistencias en una unidad de cuidados intensivos de adultos de un hospital de tercer nivel / Pneumonia nosocomial and multiresistances in adult in a tertiary referral hospital

OBJETIVO: Determinar la incidencia y etiología de la Neumonía Nosocomial (NN) en la Unidad de Cuidados Intensivos (UCI) de adultos del Hospital Universitario Reina Sofía (HURS) de Córdoba. METODOLOGÍA: El Servicio de Medicina Preventiva del HURS elaboró un estudio epidemiológico observacional de cohortes prospectivo de los pacientes ingresados en la UCI de adultos entre 2006 y 2009. Se calcularon las siguientes medidas de incidencia: Incidencia Acumulada (IA) de pacientes infectados con NN, IA de neumonías y densidad de incidencia de neumonías asociadas a ventilación mecánica. Se procedió a realizar una estadística descriptiva con cálculos de frecuencias. RESULTADOS: Hubo 233 pacientes con NN (IA de pacientes con NN=5,3/100 pacientes ingresados). El 96,6% de los pacientes con NN habían estado sometidos a ventilación mecánica (VM)previa. La tasa de incidencia de NN asociada VM fue de 15,7/1000 días de ventilación. Se solicitaron cultivos en todas las NN. El microorganismo más frecuente causante de NN fue Acinetobacter spp. (41,7% de los aislamientos), seguido de P.aeruginosa (8%), S. aureus y C. albicans, ambos aislados en un 7,1% de los cultivos. El 40% de las NN fueron provocadas por microorganismos multirresistentes, destacando el A. baumannii (82,6%) seguido de S. aureus meticilin resistente (9,7%). Destaca la emergencia de Stenothropomonas maltophilia (3,9%). CONCLUSIÓN: Las cifras de incidencia de NN en la UCI han disminuido en la última década, pero siguen siendo superiores a las de otros estudios. Los microorganismos más frecuentemente involucrados en la neumonía han sido los gramnegativos, y de ellos en primer lugar A. baumannii. Prácticamente la totalidad de los aislamientos de este microorganismo fueron multirresistentes

OBJECTIVE: To determine the incidence and etiology of Nosocomial pneumonia (NP) in adult ICU of Reina Sofia University Hospital (RSUH) of Córdoba. METHODOLOGY: The Department of Preventive Medicine of RSUH conducted a prospective cohort study for admitted patients at adults’ ICU from 2006 to 2009. The following incidence rates were calculated: accumulated incidence (AI) rate of patients with NP and incidence density of pneumonia associated with mechanical ventilation. We conducted a descriptive statistical analysis with calculation of the frequencies. RESULTS: There were registered 233 patients with NP (AI of NP of admitted patients 5.3/100). About 96.6% of patients with NP were previously subjected to mechanical ventilation (MV). The incidence rate of NP associated MV was 15.7/1000 days of ventilation. Culture was requested to all cases with NP. The most frequent microorganism of NP was Acinetobacter spp. (41.7% of cultures) followed by P.aeruginosa (8%). S.aureus and C.albicans were isolated in 7% of cultures. About 40% of NP were caused by multidrug-resistant microorganisms, like A.baumannii (82.6%) followed by methicillin resistant S. aureus (9.7%). Also we noted the emergence of Stenothropomonas maltophilia (3.9%). CONCLUSION: Incidence rates of NP in the ICU have declined in the last decade, although our rates are still higher than the reported in other studies. The microorganisms most frequently involved in NP were gram negative, of which the most frequent was A.baumannii. Nearly all isolated microorganisms were multidrug-resistant

Underlying illness severity and outcome of nosocomial pneumonia: prospective cohort study in intensive care unit.

BACKGROUND: Previous studies have suggested that the final outcome of a patient with nosocomial pneumonia (NP) may depend on the patient's illness severity upon admission to the intensive care unit (ICU). AIM: To investigate the relationship between developing NP during hospitalization in an adult ICU and the risk of death with special focus on illness severity at admission in the unit. METHODS: A prospective cohort study was performed among all patients admitted for at least 24h to the ICU of a university reference hospital in Spain from 2006 to 2009. A stratified univariate study was performed according to the patients' illness severity at admission, estimated using the Acute Physiology And Chronic Health Evaluation (APACHE) II index. To determine whether the NP was independently associated with increased mortality in ICU, a multivariate logistic regression analysis was carried out, adjusting for potential confounders. RESULTS: In all, 4427 patients were studied, of whom 233 acquired NP while admitted. Patients who developed NP had a 2.6 higher risk (95% confidence interval: 2.1-3.0) of dying compared with those who did not develop NP. When stratified by the APACHE II index, the significant association remained at each stratum, although the strength of the association decreased as the value of the index increased. In the multivariate analysis, NP was independently associated with death in the ICU. The interaction between NP and the APACHE II index, with a negative coefficient, was also significant. CONCLUSIONS: Developing NP while admitted to the ICU was independently associated with increased mortality. However, the strength of the association decreased as the severity of patient illness upon admission to the ICU increased, not influencing death of patients with severe APACHE II values.

Factors associated with the condoning of female genital mutilation among university students.

Female genital mutilation (FGM) is practiced in Egypt, despite its recent ban, generally in rural and uneducated communities, under unsanitary conditions and by non-medical personnel. Immediate and long-term complications are frequent. The aim of this study was to gain insight into what beliefs or knowledge are conducive to supporting FGM. One thousand and seventy university students in Cairo, Egypt were randomly selected. A 32-item questionnaire was used to interview students regarding their knowledge and attitudes toward FGM. Multivariable analyses were performed to find factors associated with being against the abolishment of FGM.The response rate was 95% (n=1020). Twenty-eight percent of the students support FGM. The most significant factors associated with the condoning of FGM were believing FGM has a religious basis (OR=2.53), disagreeing that FGM is a custom with no other basis (OR=2.59), not believing it is harmful (OR=4.11), and ignoring that it is usually followed by complications (OR=5.14). Even in an educated population, a considerable amount of ignorance concerning FGM exists. Widespread education about FGM is important to dispel the myths that surround its practice and to bring the practice to an end.

Comparison of different methodological approaches to identify risk factors of nosocomial infection in intensive care units.

OBJECTIVE: Comparison of statistical methods and measurement scales to identify nosocomial infection risk factors in intensive care units (ICU). DESIGN: Prospective study in 558 patients admitted to the ICU of a referral hospital between February and November 1994. METHODS: Analysis using three logistic regression models, three standard Cox regression models, and two Cox regression models with time-dependent extrinsic factors. Different scales were used to measure exposures to risk factors (dichotomous, ordinal, quantitative, and time-dependent variables). RESULTS: The most appropriate models were those that measured exposure using dichotomous variables. Models using ordinal or quantitative variables estimated biased coefficients and/or failed to comply with the statistical assumptions underlying the analyses. The Cox regression model with quantitative time-dependent variables met all the statistical assumptions, obtained a precise assessment of risk by exposure time, and estimated unbiased coefficients. CONCLUSIONS: The Cox regression analysis with quantitative time-dependent variables is the most valid alternative for assessing the risk of nosocomial infection per day of exposure to an extrinsic risk factor in the ICU.

[Study of 13 cases of anisakiasis in the province of Cordoba]. / Estudio de 13 casos de anisakiasis en la provincia de Córdoba.

Anisakiasis, or anisakidosis, is a parasitic zoonosis due to the infestation by nematodes of the Anisakidae family, mainly by Anisakis simplex. Notwithstanding its world wide distribution, in our country its appearance is quite recent (1991) with only 19 cases previously reported. We refer 13 cases diagnosed in different hospitals in the province of Córdoba, Spain, from September 1994 to July 1998 which represents the biggest series described in Spain so far. All the patients had a clinical onset as acute abdomen, so that they required early surgery in which a narrowing and inflammatory intestinal segment was observed and subsequently resected. Pathology revealed in such segments an intense eosinophilic infiltrate in the mucosa. Only in one of the cases parasitic fragments were detected in the intestinal mucosa and in the 12 remaining cases the diagnosis was immunological by IgE specific for Anisakis simplex determination and antigens detection of the nematode with monoclonal antibodies. As interesting epidemiologic antecedent we shall mention the fact that all patients referred a usual raw fish consumption (mainly anchovy with vinegar) which is host of third-stage larval of the parasite.

[Influence of nosocomial infection on mortality in an intensive care unit]. / Influencia de la infección nosocomial sobre la mortalidad en una Unidad de Cuidados Intensivos.

OBJECTIVE: To evaluate the association between nosocomial infections (NI) and the mortality of Intensive Care Unit (ICU) patients, adjusting for the effect on mortality of other predictive variables. METHODS: Prospective study on 944 concurrent patients admitted for at least 24 hours in the ICU of a tertiary level hospital between February and November of 1994. The association between NI (diagnosed using CDC criteria) and mortality was studied using multivariable logistic regression. RESULTS: The cummulative incidence of mortality in the ICU was 11.2% (CI95% = 9.9-12.5). This incidence was significantly higher in infected patients with a crude mortality relative risk of 2.2 (CI95% = 1.5-3.1). In the multivariable analysis, the effect of NI (global, pneumonias, of the urinary tract and bacteriemias) on adjusted mortality depended on the patient's Acute Pysiology and Chronic Health Evaluation II (APACHE II) score. With low APACHE II scores, NI was associated with an increased mortality risk. Conversely, with higher APACHE II scores, the relevance of NI as a determinant of mortality decreased and prognosis was mainly associated with the patient's severity of illness. CONCLUSIONS: The association between NI and mortality, adjusting for other prognostic factors for mortality, is confirmed.

[Factors associated with accidents caused by percutaneous exposure in nursing staff at a tertiary level hospital]. / Factores asociados a los accidentes por exposición percutánea en personal de enfermería de un hospital de tercer nivel.

BACKGROUND: Accidents resulting from percutaneous exposure account for approximately one third of all accidents suffered at work by health workers in hospitals. Their importance lies in the illnesses caused by pathogens that can be transmitted in this way (hepatitis B, hepatitis C, HIV virus). The aims are to describe accidents of this type notified in a tertiary level hospital, identify factors associated with these accidents in nursing staff and build a predictive model for the individual risk of having an accident. METHODS: A descriptive study of a retrospective cohort made up of all the people who notified having suffered an accident between 1-1-93 and 30-6-96. A study of cases and controls in nursing staff during the period 1-1-95 to 30-6-96, analysed through multiple logistical regression. RESULTS: The cumulative incidence of cases of accidents in one year was 0.078 for male and female nurses. In 57.3% of cases, disposable or pre-loaded syringes were involved. The cumulative incidence of cases in one year was greater for intravenous catheterisation (8.5% per 100,000). The risk of having an accident, adjusted on account of confusing variables, was greater for female and male nurses (OR = 3.22; I.C.95% = 1.96-5.27), or workers in the Haemodialysis Unit (OR = 35.21; I.C.95% = 3.74-331.16) and for those employed on a temporary contract (OR = 4.50; I.C.95% = 2.24-9.04). CONCLUSIONS: Accidents resulting from percutaneous exposure at this hospital are more frequent among nursing staff and are basically caused by any type of hollow needles. Factors associated with these accidents were identified, allowing specific prevention programmes to be targeted at those workers at greater risk. The model obtained is valid to estimate the degree of individual accident probability for the subjects studied.

[Abnormally broad confidence intervals in logistic regression: interpretation of results of statistical programs]. / Intervalos de confianza anormalmente amplios en regresión logística: interpretación de resultados de programas estadísticos.

This study describes the behavior of eight statistical programs (BMDP, EGRET, JMP, SAS, SPSS, STATA, STATISTIX, and SYSTAT) when performing a logistic regression with a simulated data set that contains a numerical problem created by the presence of a cell value equal to zero. The programs respond in different ways to this problem. Most of them give a warning, although many simultaneously present incorrect results, among which are confidence intervals that tend toward infinity. Such results can mislead the user. Various guidelines are offered for detecting these problems in actual analyses, and users are reminded of the importance of critical interpretation of the results of statistical programs.

[Mortality due to suicide in Spain: associated socioeconomic and environmental factors]. / Mortalidad por suicidio en España: factores socioeconómicos y ambientales asociados.

OBJECTIVE: Describe the cumulative incidence of suicide mortality and self-inflicted injuries in Spain during the period 1987-1991 and identify associated socioeconomic and meteorological factors. DESIGN: Ecological study. SITE: Fifty Spanish provinces excluding Ceuta and Melilla. PATIENTS: Spanish population during the study period. MAIN MEASUREMENTS AND RESULTS: For each province, the cumulative incidence of mortality from suicide and self-inflicted injuries were calculated by gender and age groups. The associations between suicide mortality and 31 socioeconomical and meteorological variables were evaluated using multiple linear regression. The incidence of suicide deaths was stable during the study period. The most important negative associations identified were with variables indicating economical development and the positive associations with the variable measuring specific general mortality. No significant differences between genders were found. For both genders, the model with the highest coefficient of determination corresponded to the group of adults aged. CONCLUSIONS: In Spain, social and economical factors are associated with the frequency of deaths from suicide and self-inflicted injuries in both genders and specially in the adult age.

[Risk factors for pneumonia, bacteremia, and urinary tract infection in an intensive care unit]. / Factores de riesgo de neumonía, bacteriemia e infección urinaria en una unidad de cuidados intensivos.

BACKGROUND: To identify nosocomial infection risk factors in an intensive care unit and construct a predictive model that will enable future risk-adjusted comparisons of infection incidences. PATIENTS AND METHODS: Prospective surveillance of pneumonia, bacteremia and urinary tract infections in intensive care unit patients. All patients (n = 944) admitted to the intensive care unit for at least 24 h were followed daily in a tertiary level hospital. Variables measuring extrinsic as well as intrinsic risk factors for nosocomial infections were collected from each patient during their intensive care unit stay and the Cox proportional hazards multivariable technique was applied to identify the variables mostly associated with infection in our hospital. RESULTS: The main risk factors identified for pneumonias were intrinsic. The hazard ratios (HR) of two extrinsic risk factors were noteworthy: mechanical ventilation (HR = 7.51; 95% CI = 2.95-19.13) and sedation (HR = 2.01; 95% CI = 1.14-3.56). The extrinsic factors associated with bacteremias were, the sum of extrinsic risk factors (HR = 1.52; 95% CI = 1.17-1.97) and having a tracheostomy (HR = 3.61; 95% CI = 1.99-6.56). The urinary tract infections were negatively associated with the administration of antibiotics prior to infection onset (HR = 0.41; 95% CI = 0.21-0.78) and the male sex (HR = 0.40; 95% CI = 0.22-0.75). Conversely, urinary tract infections were positively associated with the presence of cancer (HR = 2.70; 95% CI = 1.03-7.11) and the APACHE II index (for every 5 units of increase of the APACHE II index, HR = 1.39; 95% CI = 1.09-1.79). CONCLUSIONS: The most important risk factors identified for pneumonias and urinary tract infections in intensive care unit patients were endogenous, whereas they were exogenous for bacteremias.

[Estimation of cost associated with incorrect surgical prophylaxis in a third level hospital center]. / Estimación del coste asociado a la profilaxis quirúrgica en un centro hospitalario de tercer nivel.

BACKGROUND: The constant increase of pharmaceutical costs is of great concern to the administrators of the Spanish National Health Service. Antibiotics administered as prophilaxis prior to surgery, play an important role in this increase. The compliance of physicians with protocols for chemoprophylaxis is therefore an important factor in the control of these pharmaceutical costs. The degree of compliance with the pre-established protocols of prophylaxis prior to surgery are examined in a tertiary level hospital during 1992 and the extra costs due to the lack of compliance with these protocols are estimated using a sample of 371 subjects. The object of this study is to describe the degree of the fulfillment of the protocols of surgical chemoprophylaxis in a tertiary level hospital and to estimate the minimum additional cost due to the wrong chemoprophylaxis. METHODS: A descriptive study was made of the surgical prophylaxis using a sample of 371 subjects. The cost was estimated from the price of the antibiotics administered. RESULTS: A total of 267 (71.9% IC95% = 67.3-76.5) subjects had received incorrect prophylaxis. The most important causes of incorrect prophylaxis were the wrong antibiotic choice and the excessive duration of their administration. The incorrect prophylaxis was responsible for an additional cost of 1,117,287 ptas. The application of these estimates to the entire 1992 surgical population, at our center, would yield an estimated additional cost of 39,409,965 pesetas. CONCLUSIONS: Our health services would have substantial savings if protocols for prophylaxis prior to surgery were strictly followed by physicians.

[Accidental pricking by a needle in a third-level hospital: associated factors]. / Pinchazos accidentales con aguja en un hospital de tercer nivel: factores asociados.

The needlestick injuries are the most frequent accidents among hospital staff. The aim of this study is to identify some factors associated with accidents caused by needlestick injuries at hospitals, so as to measure the risk that they present. A case-control study has been made, the subject of which is the nurses working at "Reina Sofía" Hospital in Córdoba and within the period June 30, 1990 and June 30, 1991. A more significant factor in relation to needlestick injuries was the recapping of the needle after being used. The risk of injury being 3.95, 7.68 an 17.85 times higher between those who recapped sometimes, frequently and always, respectively, versus those who had never recapped needles. Professional experiences resulted in being a protector factor against the needlestick injuries (OR = 0.93; 95% CI = 0.89; 0.97;) it's estimated that the risk injuring is less than half among personnel having ten years of experience. Knowing these risk factors is important for the development of specific prevention programs. Nevertheless, it is still important to identify other risk factors.

[Minimal inhibitory and bactericidal concentrations of some antiseptics and disinfectants against strains of hospital origin]. / Concentraciones mínimas inhibitorias y bactericidas de algunos antisépticos y desinfectantes frente a cepas de origen hospitalario.

The MIC in solid media and the B.M.C. by the dilution-neutralization test using sterile water, was determined using 10 antiseptics and disinfectants with 70 strains of 10 species of Gram negative bacteria more frequently causing nosocomial infections in Ciudad Sanitaria Reina Sofía, Córdoba, in Spain. Relationship between the two tests was searched with no positive results. The more effective antiseptics were silver nitrate and chlorhexidine, the less active was phenol. Activity of some antiseptics was similar at 30 or 60 minutes of contact with the microorganisms.

[Clinical-epidemiological assessment of bacterial meningitis in the province of Cordoba (1983-1989)]. / Valoración clínico-epidemiológica de la meningitis bacteriana en la provincia de Cordoba (1983-1989).

533 cases of bacterial meningitis diagnosed in the province of Cordoba over a period of seven years are analyzed. 53.7% of the cases are in males, with 71.2% of the cases being detected in children under 14 (p less than 0.001). Greater incidence has been observed in Cordoba city than in the province, with a direct relationship being between morbidity and population density. The months with lower average temperature account for 45.6 por 100 of all the diagnosed cases of meningitis. By etiology, 51.9% were meningococcal meningitis, followed by meningitis produced by unknown germs (35.3%) and by H. influenzae. The illness developed in 91.3% of cases to a cure, with sequelae in 4.1% and death in 4.4%. Meningitis produced by H: influenzae was what caused most sequelae and that produced by S. pneumoniae was the most lethal. Isolated N. meningitidis presented 100% sensitivity to penicillin and cephalosporins, H. influenzae 91.7% chloramphenicol and only 28.3% to penicillin.

[Meningococcal disease in the province of Córdoba (1983-1987]. / Enfermedad meningocócica en la provincia de Córdoba (1983-1987).

This study reports the clinico-biologic characteristics, complications and the final events in 224 cases of meningococcal disease observed during a period of five years in the province of Cordoba. The prognostic factors of the disease were also evaluated. Patients were divided into three groups according to the diagnosis: meningitis, meningococcemia, and meningitis with meningococcemia. The incidence of each group was 18%, 22% and 60%, respectively. The 81.7% of the patients were below the age of 14 years. The most frequent symptoms were the fever (97.8%), vomitus (75%) and headache (52.2%) The more common exploratory findings were petechiae (76.8%) and nuchal rigidity (53.6%). Complications related to the illness were present in 27.3% of the cases. The clinical course showed a mortality rate of 6.3% with a complete recovery in 91% of patients. Sequelae was present in 2.7% of the cases. The absence of previous antibiotic therapy (p < 0.05), the presence of nuchal rigidity (p < 0.05), shock (p < 0.01), coma (p < 0.05), leukocytopenia (p < 0.001), and a prothrombin activity lower than 70% (p < 0.05) were associated with a bad prognosis.

[An epidemiological study of meningococcal disease in the province of Cordova (1983-1987)]. / Estudio epidemiológico de la enfermedad meningocócica en la provincia de Córdoba (1983-1987).

To more precisely define the epidemiological characteristics of meningococcal disease (MD) and to try to determine its possible risk factors, 224 cases diagnosed during the 1983-1987 period in all the hospitals of the Cordova province were evaluated. There was an incidence density (ID) of 6 cases/100,000/year. The younger ages were the most commonly involved (81.7% of cases were less than 14 years old), and males had the highest overall incidence. The greatest number of cases accumulated during the coldest months of the year (december, january, february). The highest rate of incidence was in the Guadalquivir Valley area, which has the highest population density. The poorest and socioeconomically lowest districts of the capital had the greatest morbidity (p less than 0.001). The mortality rate was 6.2%. It was higher in patients over 5 years of age and the male/female mortality rate was 0.75. It was concluded that wider and deeper epidemiological studies are required to evaluate the influence of habitat and other possible factors in the development of MD.

[Activity of quaternary ammonium derivatives against 145 strains of rapidly-growing atypical mycobacteria]. / Estudio de la acción de los derivados del amonio cuaternario sobre 145 cepas de microbacterias atípicas de crecimiento rápido.

A survey about 145 atypical mycobacteria strains belonging to the M. fortuitum y M. chelonae complex sensitivity in response to three quaternary ammonium derivates has been performed by means of the dilutional and agar spreading methods. High strain sensitivity has been detected, having the three investigated antiseptics a very similar behaviour. The correlation rates and the regression lines equations have been obtained. And as a result of the high values we have obtained, it's possible to get the strain CMI directly from the corresponding inhibition halo.

[Hospital infection and resistance to antibiotics at a pediatric intensive care unit]. / Infección hospitalaria y resistencia a antimicrobianos en una unidad de cuidados intensivos de pediatría.

A retrospective study of nosocomial infection and its aetiological agents antimicrobial sensitivity in a pediatric ICU during 65 months is reported. Using statistical analysis association was found between infection site and certain diagnostic-therapeutic procedures, such as urinary infection and urinary tract catheter, respiratory lower tract infection and respiratory assistance devices, bacteremia with intravenous catheters. Also found relationship between age and causal agents: Streptococcus faecalis is the main microorganism in newborns and Pseudomonas aeruginosa in older patients. Gram negative bacilli sensitivity increased significantly for some antimicrobial drugs: carbenicillin, cefotaxime, gentamicin, fosfomycin and tobramycin, whereas gram positive microorganisms sensitivity decreased to cephalothin, cefoxitin, trimethoprim-sulphamethoxazole and gentamicin.