Antimicrobial resistance in Gram-negative bacilli in Spain: an experts' view.

BACKGROUND: Antibiotic resistance in Gram-negative bacilli poses a serious problem for public health. In hospitals, in addition to high mortality rates, the emergence and spread of resistance to practically all antibiotics restricts therapeutic options against serious and frequent infections. OBJECTIVE: The aim of this work is to present the views of a group of experts on the following aspects regarding resistance to antimicrobial agents in Gram-negative bacilli: 1) the current epidemiology in Spain, 2) how it is related to local clinical practice and 3) new therapies in this area, based on currently available evidence. METHODS: After reviewing the most noteworthy evidence, the most relevant data on these three aspects were presented at a national meeting to 99 experts in infectious diseases, clinical microbiology, internal medicine, intensive care medicine, anaesthesiology and hospital pharmacy. RESULTS AND CONCLUSIONS: Subsequent local debates among these experts led to conclusions in this matter, including the opinion that the approval of new antibiotics makes it necessary to train the specialists involved in order to optimise how they use them and improve health outcomes; microbiology laboratories in hospitals must be available throughout a continuous timetable; all antibiotics must be available when needed and it is necessary to learn to use them correctly; and the Antimicrobial Stewardship Programs (ASP) play a key role in quickly allocating the new antibiotics within the guidelines and ensure appropriate use of them.

Management of Patients with Suspected or Confirmed Antibiotic Allergy: Executive Summary of Guidelines from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Allergy and Clinical Immunology (SEAIC), the Spanish Society of Hospital Pharmacy (SEFH) and the Spanish Society of Intensive Medicine and Coronary Care Units (SEMICYUC).

Suspected or confirmed antibiotic allergy is a frequent clinical circumstance that influences antimicrobial prescription and often leads to the avoidable use of less efficacious and/or more toxic or costly drugs than first-line antimicrobials. Optimizing antimicrobial therapy in patients with antibiotic allergy labels has become one of the priorities of antimicrobial stewardship programs in several countries. These guidelines aim to make recommendations for the systematic approach to patients with suspected or confirmed antibiotic allergy based on current evidence. An expert panel (11 members of various scientific societies) formulated questions about the management of patients with suspected or confirmed antibiotic allergy. A systematic literature review was performed by a medical librarian. The questions were distributed among panel members who selected the most relevant references, summarized the evidence, and formulated graded recommendations when possible. The answers to all the questions were finally reviewed by all panel members. A systematic approach to patients with suspected or confirmed antibiotic allergy was recommended to improve antibiotic selection and, consequently, clinical outcomes. A clinically oriented, 3-category risk-stratification strategy was recommended for patients with suspected antibiotic allergy. Complementary assessments should consider both clinical risk category and preferred antibiotic agent. Empirical therapy recommendations for the most relevant clinical syndromes in patients with suspected or confirmed ß-lactam allergy were formulated, as were recommendations on the implementation and monitoring of the impact of the guidelines. Antimicrobial stewardship programs and allergists should design and implement activities that facilitate the most appropriate use of antibiotics in these patients.

Management of Patients with Suspected or Confirmed Antibiotic Allergy: Executive Summary of Guidelines from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Allergy and Clinical Immunology (SEAIC), the Spanish Society of Hospital Pharmacy (SEFH) and the Spanish Society of Intensive Medicine and Coronary Care Units (SEMICYUC)

Suspected or confirmed antibiotic allergy is a frequent clinical circumstance that influences antimicrobial prescription and often leads to the avoidable use of less efficacious and/or more toxic or costly drugs than first-line antimicrobials. Optimizing antimicrobial therapy in patients with antibiotic allergy labels has become one of the priorities of antimicrobial stewardship programs in several countries. These guidelines aim to make recommendations for the systematic approach to patients with suspected or confirmed antibiotic allergy based on current evidence. An expert panel (11 members of various scientific societies) formulated questions about the management of patients with suspected or confirmed antibiotic allergy. A systematic literature review was performed by a medical librarian. The questions were distributed among panel members who selected the most relevant references, summarized the evidence, and formulated graded recommendations when possible. The answers to all the questions were finally reviewed by all panel members. A systematic approach to patients with suspected or confirmed antibiotic allergy was recommended to improve antibiotic selection and, consequently, clinical outcomes. A clinically oriented, 3-category risk-stratification strategy was recommended for patients with suspected antibiotic allergy. Complementary assessments should consider both clinical risk category and preferred antibiotic agent. Empirical therapy recommendations for the most relevant clinical syndromes in patients with suspected or confirmed ß-lactam allergy were formulated, as were recommendations on the implementation and monitoring of the impact of the guidelines. Antimicrobial stewardship programs and allergists should design and implement activities that facilitate the most appropriate use of antibiotics in these patients (AU)

En la práctica clínica, un antecedente de alergia a los antibióticos, confirmada o sospechada, es frecuente y condiciona la selección de antibióticos, requiriendo con frecuencia el uso de fármacos menos eficaces, más tóxicos o más caros que los antibióticos de primera línea. La optimización del uso de antibióticos en pacientes con este antecedente es una de las prioridades de los programas de optimización de uso de antibióticos (PROA) en varios países. Estas guías pretenden formular recomendaciones para evaluar de una manera sistemática a estos pacientes mediante una aproximación basada en la evidencia. Un panel multidisciplinar constituido por alergólogos, infectólogos, farmacéuticos hospitalarios e intensivistas formularon una serie de preguntas sobre el manejo de estos pacientes; una documentalista realizó la revisión bibliográfica. Las preguntas se distribuyeron entre los miembros del grupo de trabajo, quienes seleccionaron las referencias más relevantes y formularon las correspondientes recomendaciones, que fueron revisadas y aprobadas por todos los miembros del grupo. Es necesaria una aproximación sistemática a los pacientes con antecedentes de alergia a antibióticos para optimizar la selección del tratamiento antibiótico y mejorar los resultados clínicos de estos pacientes cuando precisan antibioterapia. El presente documento recomienda una estrategia de estratificación clínica del riesgo en 3 categorías. La recomendación de realizar evaluaciones complementarias se basa en el riesgo clínico y el antibiótico de primera línea necesario. Además, se formulan recomendaciones de tratamiento antibiótico empírico para los principales síndromes infecciosos en pacientes con alergia confirmada o sospechada. Finalmente, se formulan recomendaciones sobre la implementación y monitorización del impacto de las recomendaciones de la guía (AU)

Epidemiologic changes in bloodstream infections in Andalucía (Spain) during the last decade.

OBJECTIVES: During the last decade, some changes in the epidemiology of invasive infections have been reported; however, specific studies with patient-level data are scarce. The aim of this study was to describe and evaluate the epidemiologic changes in bloodstream infections (BSI) during the last decade in Andalucía, Spain. METHODS: Data from two prospective cohorts of BSI in adults with the same methodology performed 10 years apart in 11 hospitals (eight tertiary and three community) in Andalucía, Spain, were compared; the 2006-7 cohort study was performed between October 2006 and March 2007, and the 2016-17 cohort study was performed between October 2016 and March 2017. Population-based incidence rates were calculated and extrapolated for 1 year. Relative risk ratios were calculated between the 2 periods. Multivariate analyses were performed by logistic regression. RESULTS: Overall, 1262 episodes of BSI were included, 563 (44.6%) in 2006-7 and 699 (55.3%) in 2016-17. Multivariate models selected the following changes in patients' features in 2016-17, after controlling for type of acquisition: higher age (odds ratio (OR) = 1.02; 95% confidence interval [CI] 1.01-1.03), lower urinary catheter (OR = 0.37; 95% CI, 0.26-0.48) and lower Pitt score (OR = 0.76; 95% CI, 0.71-0.82). Adjusted estimations considering patients' features and exposure to procedures showed a reduction in coagulase-negative staphylococci (OR = 0.47; 95% CI, 0.32-0.69), and an increase in Proteus spp. (OR = 3.12; 95% CI, 1.18-8.23) and Candida spp. (OR = 3.01; 95% CI, 1.03-8.86). CONCLUSIONS: We found relevant epidemiologic changes in BSI in our area, including rates, frequency of acquisition types, changes in patient's profiles and aetiologic agents.

Effects of equal-volume resistance training performed one or two times a week in upper body muscle size and strength of untrained young men.

AIM: The purpose of the present study was to compare the effects of equal-volume resistance training (RT) performed once or twice a week on muscle mass and strength of the elbow flexors in untrained young men. METHODS: Thirty men (23 ± 3 years) without previous resistance training experience were divided into two groups: Group 1 (G1) trained each muscle group only once a week and group 2 (G2) trained each muscle twice a week during 10 weeks. Baseline and 10 weeks post-test elbow flexors muscle thickness (MT) were measured using a B-Mode ultrasound. Peak torque (PT) was assessed by an isokinetic dynamometer before and after the training program. RESULTS: Elbow flexors MT increased significantly (P<0.05) from 31.70 ± 3.31 to 33.43 ± 3.46 mm in G1, and from 32.78 ± 4.03 to 35.09 ± 3.55 mm in G2. Elbow flexors PT also increased (P<0.05) from 50.77 ± 9.26 to 54.15 ± 10.79 N.m in G1, and from 48.99 ± 11.52 to 55.29 ± 10.24 N.m in G2. The results of ANOVA did not reveal group by time interactions for any variable, indicating no difference between groups for the changes in MT or PT. CONCLUSION: The results from the present study suggest that untrained men experience similar gains in muscle mass and strength with equal volume RT performed one or two days per week.

Brazilian obesity prevention and control initiatives.

Obesity prevalence in the Brazilian adult population is 12.5% among men and 16.9% among women. Obesity control has been a subject of concern in Brazilian health policies since the publication of the National Food and Nutrition Policy in 1999. The initiatives include a comprehensive national intersectorial plan for obesity prevention and control focused on confronting its social and environmental causes, development of a food and nutrition education framework aimed at intersectorial public policies in the food and nutritional security field, promotion and provision of healthy food in school environments (linked to family farming), structuring nutrition actions in primary healthcare in the national healthcare system, promoting community physical activity, food regulation and control, and encouragement of public participation and food control. We conclude that several initiatives have been developed in Brazil to deal with the challenge of implementing an intergovernmental, intersectorial response to reverse the rising overweight and obesity rates. The success of this response will depend on a governance model that promotes joint and integrated action by different sectors and active participation of society to consolidate the actions, places and laws that protect health and promote healthy lifestyles.

Effects of power training on muscle thickness of older men.

The present study aimed at comparing the effects of traditional resistance training (TRT) and power training (PT) in inducing muscle hypertrophy in older men. Twenty older men (aged between 69 and 76 years) were divided in two groups: TRT training (n=9) and PT training (n=11). The volunteers trained twice a week, during 10 weeks. Both groups performed an equal work output and the same exercises with loads between 40% and 60% of 1 RM. Three sets of eight repetitions of each exercise were performed with rest intervals of 90 s between sets. Muscle thickness was measured by ultrasound at the biceps brachii (BIC) and rectus femoris (RF), using a 12 MHz high resolution scanning probe. An ANCOVA was used to compare post training muscle thickness values between TRT and PT, using baseline values as covariates. According to the results, RF muscle thickness increased only in PT, while BIC muscle thickness increased in both groups, but with larger increases in PT. In conclusion, ten weeks of PT induced muscle hypertrophy of the upper and lower limb muscles in older men. PT training may yield better results in muscle hypertrophy when compared with TRT.

Physical activity, Cdx-2 genotype, and BMD.

The present study investigated the interaction between Cdx-2 polymorphism and physical activity level over bone mineral density (BMD) variation in Brazilian postmenopausal women. One hundred and ninety women volunteered to participate in the study (66.6 +/- 5.3 years, 64.58 +/- 11.74 kg and 151.94 +/- 6.36 cm). Physical activity level (PAL) was assessed using the international physical activity questionnaire (IPAQ). Lumbar spine (L2 - L4), femoral neck, great trochanter and Wards' triangle bone mineral density (BMD) were measured by dual-energy X-ray absorptiometry (DXA). The Cdx-2 polymorphism was genotyped by minisequencing, using the SNaPshottrade mark Multiplex System (Applied Biosystems, Foster City, CA, USA). Overall, no significant association was found between Cdx-2 polymorphism and adjusted BMD at any site. However, the results revealed a significant interaction between PAL and Cdx-2 genotype on adjusted femoral neck and Wards' triangle BMD. Active women carrying the Cdx-G/G genotype showed higher adjusted femoral neck and Wards' triangle BMD than inactive women carrying the same genotype, thus suggesting a larger chronic response to physical activity. These results suggest that, in postmenopausal women, the Cdx-2 polymorphism does not influence BMD by itself; however, it seems to affect the BMD response to physical activity since only the Cdx-G/G genotype carriers presented significant differences between active and inactive.

A multiplex single-base extension protocol for genotyping Cdx2, FokI, BsmI, ApaI, and TaqI polymorphisms of the vitamin D receptor gene.

The well-described role of the vitamin D endocrine system in bone metabolism makes its receptor a widely investigated candidate gene in association studies looking for the genetic basis of complex bone-related phenotypes. Most association studies genotype five polymorphic sites along the gene using PCR-RFLP and allele-specific amplification methods, which may not be the better choice in large case/control or cross-sectional studies. In this case, genotyping SNPs in parallel and using automated allele-calling methods are important to decrease genotyping errors due to manual data handling and save sample in cases where the amount of DNA is limited. The aim of this study was to present a straightforward method based on multiplex PCR amplification followed by multiplex single-base extension as a simple way to genotype five vitamin D receptor gene polymorphisms in parallel, which may be implemented in medium- to large-scale case/control or cross-sectional studies. The results regarding method feasibility and optimization are presented by genotyping eight paternity trios and seven samples of Brazilian postmenopausal women who took part in an ongoing association study carried out by members of our group.

A multiplex single-base extension protocol for genotyping Cdx2, FokI, BsmI, ApaI, and TaqI polymorphisms of the vitamin D receptor gene

The well-described role of the vitamin D endocrine system in bone metabolism makes its receptor a widely investigated candidate gene in association studies looking for the genetic basis of complex bone-related phenotypes. Most association studies genotype five polymorphic sites along the gene using PCR-RFLP and allele-specific amplification methods, which may not be the better choice in large case/control or cross-sectional studies. In this case, genotyping SNPs in parallel and using automated allele-calling methods are important to decrease genotyping errors due to manual data handling and save sample in cases where the amount of DNA is limited. The aim of this study was to present a straightforward method based on multiplex PCR amplification followed by multiplex single-base extension as a simple way to genotype five vitamin D receptor gene polymorphisms in parallel, which may be implemented in medium- to large-scale case/control or cross-sectional studies. The results regarding method feasibility and optimization are presented by genotyping eight paternity trios and seven samples of Brazilian postmenopausal women who took part in an ongoing association study carried out by members of our group.

Implantación de sistemas de autocontrol en la cadena del frío de los Centros de vacunación / Implement of self monitoring systems of vaccines cold chain in vaccination centers

Para que el proceso de vacunación se lleve a cabo con éxito son necesarias, no sólo vacunas seguras y eficaces, sino que además, se debe asegurar el mantenimiento de la cadena del frío. Las referencias bibliográficas que hacen alusión a errores en la cadena del frío y a las consecuencias de éstos son numerosas y, en la mayoría de los casos, se podrían haber evitado con una infraestructura adecuada de mantenimiento y una serie de medidas preventivas y controles que habrían reducido los riesgos o al menos habrían permitido actuar precozmente. En el presente trabajo se hace una propuesta de autocontrol en la cadena del frío de los Centros de vacunación, basada en la Norma ISO 9000 y tomando como referencia las principales conductas de riesgo, por acción o por omisión, encontradas en la bibliografía, así como la propia experiencia y los datos generados con la verificación de la cadena del frío en los Centros de vacunación de un Área sanitaria. Se plantea por ello, el desarrollo de cuatro planes preventivos generales, los cuales pretenden abordar cualquier situación de riesgo que pueda afectar a la calidad de las vacunas (AU)

Tratamiento de la pediculosis. Alternativas ante la evidencia de resistencia a los tratamientos actuales / The treatment of pediculosis capitis. Alternatives in the evidence of resistance to current treatments

Los piojos de la cabeza son un problema de ámbito mundial, aunque no suponen un peligro para la Salud Pública al no transmitir enfermedades, pero sí por el mal uso de los tratamientos. Actualmente, la terapéutica estándar consiste en la aplicación de pediculicidas por vía tópica (en algunos países también se utiliza la vía oral). El tratamiento utilizado en algunos países como Estados Unidos y Reino Unido, consiste en la administración de forma rotatoria de una misma sustancia, normalmente de libre dispensación, constituidas fundamentalmente por Permetrina y Piretrinas, reservando para prescripción médica sustancias como Carbaril o Malatión. En cambio, en España, sustancias como Permetrina, Piretrinas, Malatión y Lindano son de libre dispensación, no siendo sometidos a ningún control de uso por parte de la Administración Sanitaria. Esto está llevando a que se produzcan numerosas resistencias y que se den casos en los que ninguno de los anteriores productos sean eficaces.Se revisan también otras alternativas de tratamiento (AU)

Biomechanical evaluation of different instrumentation for spinal stabilisation.

The varying problems following arthrodesis of the lumbar spine with rods or plates (too much rigidity for the first and insufficient stability for the second) have led us to conceive another type of material, flexible but with enough stability, to favorise healing of bone graft, and decrease the induced pathology on adjacent levels. An experimental study of three types of material: rigid, semi-rigid and flexible was performed on eighteen fresh cadaver spinal segments without and then with discectomy and corporectomy to find out the various types of behaviour. The flexible device seems more supple than the other materials tested: more mobility, less stiffness. Rising hysteresis is explained by plastic deformation. The semi-rigid device presents strong osseous stresses on the L3 level and a large hysteresis corresponding most likely to a mobility between the screws and plates. The rigid device has less mobility, especially in torsion, ascribed to the transverse connection. The stability is high with a small hysteresis. This is of value for bone loss or instability with displacement of the vertebral body.The second study was a modeling of the flexible device validated by comparison to the experimental study. The strains in the wire were high, decreasing with increasing diameter, but is still lower than the elastic limit. The proximity of the elastic limit may allow plastic deformation of the wire. Howewer less strains were found on the screw fixation but increase with the increase diameter of the wire. The influence of the bone quality on the behavior of the device was demonstrated.

Surgical treatment of prolactinomas. Short- and long-term results, prognostic factors.

All 347 patients surgically treated for a prolactinoma from January 1, 1976 to December 31, 1982, in the neurosurgical ward of Foch Hospital, were retrospectively studied. The frequency of postoperative normalisation of plasma prolactin (PRL) depends on prolactinoma size, preoperative PRL level, duration of first clinical symptom, previous oestroprogestative contraception, and adenoma necrosis. Postoperative PRL values were normalized in 75% of small prolactinomas (grade 0, 1 or 2) with preoperative PRL values less than 200 ng/ml, and clinical duration less than 5 years (n = 102). There was no operative death and minor morbidity (2.7%). Among the 96 patients with postoperative PRL normalisation, operated between 1976 and 1979, 70 were followed up for an average time of 4.4 +/- 0.2 years. 17% of patients had hyperprolactinemia recurrence with a delay of 1.5 +/- 0.4 years. Postoperative PRL levels near the upper normal limit, and weak PRL response to TRH tests were found to be unfavourable prognostic factors for hyperprolactinemia recurrence. Pregnancy did not increase the risk of recurrence, but could reflect genuine long-lasting remission. Selective adenomectomy remains an interesting treatment for prolactinoma, particularly if the adenoma is small, recent and with PRL moderately increased. The frequency of postoperative PRL normalisation after surgery is less than with bromocriptine, but surgery is the only treatment able to achieve a definitive cure with a low iatrogenic risk.

Endocrine outcome after transsphenoidal adenomectomy for prolactinoma: prolactin levels and tumor size as predicting factors.

The level of prolactin in the serum was determined pre- and postoperatively in 90 patients who were operated upon transsphenoidally for prolactin-secreting pituitary adenomas. Twenty-three had microadenomas and 67 had macroadenomas. Those patients who were cured had a distinctly lower mean prolactin level (about 200 ng/ml or less) than those who were not cured. Of those patients whose adenomas were larger than 10 mm in diameter, only 39% were cured. The relationship between prolactin levels and tumor size and the return of menses and cure is discussed.

[Renal function and histologic studies in rats treated by floctafenin (author's transl)]. / Etudes fonctionnelle et histologique rénales chez le rat soumis à un traitement prolongé par la floctafénine.

The nephrotoxic action of floctafenin has been studied in rats. When administered orally at 20 or 50 mg/kg/day for 20 or 50 days, this analgesic agent had no effect on the renal function, either in intact rats or in animal with reduced renal parenchyma. There is no histological change in the kidneys of the treated animals except some focal dilatations of the distal tubules. The tubular alterations were more important in treated and untreated rats with nephronic reduction. The whole body autoradiographic studies of rats treated with 14C floctafenin showed that liver and kidney accumulate radioactivity, and that the intake of radiolabeled compounds is twice higher in renal cortex than in medulla. This study suggests that the toxicity of floctafenin for the rat kidney is very low or none.