[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.

Diagnóstico de la espondilodiscitis brucelar en urgencias / Brucellar spondylodiscitis in the emergency department

La lumbalgia es uno de los síntomas guía en la presentación de la espondilodiscitis infecciosa, que puede pasar desapercibida si no se tiene en cuenta la importancia de la anamnesis y las pruebas complementarias iniciales. Presentamos dos casos de espondilodiscitis por Brucella que consultaron por lumbalgia al servicio de urgencias. Revisamos la presentación clínica y los métodos diagnósticos de esta complicación, con especial atención al manejo que debe hacerse en urgencias (AU)

Low back pain is a key symptom of infectious spondylodiscitis, a condition that may be overlooked if attention is not focused on the patient’s medical history and the initial set of tests. We report the cases of 2 patients diagnosed with spondylodiscitis due to Brucella species who came to the emergency department because of low back pain. We review the presenting symptoms of this complication and the diagnostic methods used, and pay particular attention to the treatment that should be initiated in the emergency department (AU)

Edema pulmonar en el tromboembolismo pulmonar masivo / Pulmonary oedema in massive pulmonary thromboembolism

La aparición de un infiltrado alveolar bilateral en el contexto de un episodio agudo de tromboembolismo pulmonar (TP) es un hecho infrecuente que puede producirse por diversas causas con diferente mecanismo fisiopatológico. Entre ellas se encuentran la aparición de un síndrome de distrés respiratorio del adulto, el desarrollo de insuficiencia cardiaca, el edema por sobreperfusión y el edema por reperfusión. Presentamos el caso de un paciente con TP masivo que fue tratado con fibrinolisis sistémica y que desarrolló un infiltrado pulmonar bilateral extenso con hipoxemia grave y necesidad de ventilación mecánica. Se discuten las distintas causas que pudieron precipitar esta evolución (AU)

The appearance of bilateral pulmonary infiltrates during acute pulmonary embolism is a rare event. It may be produced by several causes with different physiopathologyc mechanism, such as the appearance of adult respiratory distress syndrome, development of cardiac failure, overperfusion edema and reperfusion edema. We report the case of a patient with massive pulmonary embolism that was treated with systemic thrombolysis, who developed bilateral diffuse pulmonary infiltrates with severe hypoxia requiring mechanical ventilation. We discuss the different causes that could precipitate this evolution (AU)