Quality control of the surveillance programme of ICU-acquired infection (ENVIN-HELICS registry) in Spain.

BACKGROUND: Data validation is an essential aspect for the accuracy of a nosocomial infection surveillance registry. AIM: To report the results of the first quality control programme in the national surveillance programme of intensive care unit (ICU)-acquired infection in Spain (ENVIN-HELICS registry). METHOD: During 2008, of 13,824 records included in the database, 1500 (10.8%) registries from 20 ICUs were reviewed. These ICUs were selected at random and stratified according to the number of cases included in the registry. The proportion of infected patients, which was 9.6% [95% confidence interval (CI) 8.09-11.16], was maintained during the selection of cases for review. Two physicians were trained for the purpose of the study and undertook the review. RESULTS: Overall sensitivity, specificity and positive and negative predictive values of the ENVIN-HELICS registry for the identification of patients with any device-related infection acquired during their ICU stay were 86.0% (95% CI 80.0-92.0), 98.7% (95% CI 82.19-93.6), 87.9% (95% CI 82.19-93.6) and 98.5% (95% CI 97.8-99.2), respectively, with a kappa index of 0.85 (95% CI 0.79-0.92). Secondary bloodstream infection had the lowest sensitivity (59.3%), and intubation-associated pneumonia had the highest sensitivity (86.3%). CONCLUSION: There was good correlation between data reported by the registrars and data validated by auditors, confirming the reliability of the ENVIN-HELICS registry.

Epidemiologia de las bacteriemias primarias y relacionadas con cateteres vasculares en pacientes criticos ingresados en servicios de medicina intensiva / Epidemiology of the primary and vascular catheter-related bacteriemias in critical patients admitted to an Intensive Medicine Department

Objetivo: En los últimos años se han producido cambios en el entorno de la bacteriemia relacionada con el uso de catéteres vasculares (BCV) con la aparición de cocos grampositivos multirresistentes (CGP-MR), el conocimiento de limitaciones en los antibióticos más utilizados para su tratamiento (glucopéptidos) y la aparición de nuevos antibióticos activos vs. dichos patógenos. En este artículo se analiza la evolución de las tasas, etiologías y marcadores de multirresistencia de los patógenos más comunesen las BCV (incluidas las bacteriemias primarias) en servicios de medicina intensiva españoles (UCI). Material y métodos: Estudio de incidencia, multicéntrico, prospectivo, observacional y de participación voluntaria. Han colaborado 74, 105, 112 y 121 UCI pertenecientes a 71, 97, 103 y 112 hospitales respectivamente entre los años 2005-2008 (ambos inclusive). Se ha utilizado la información incluida en el registro ENVIN-HELICS. Resultados: Las tasas de esta complicación han disminuido y se sitúan en torno a 5 episodios por 1.000 días de catéter venoso central (CVC). Una tercera parte de los episodios se presentan con una importante respuesta sistémica (sepsis grave o shock séptico). Los CGP-MR fueron los más frecuentes pero los bacilos gramnegativos (BGN) se identificaron en el 30% de casos y los hongos (distintas especies de Candida) en el 6%. Los Staphylococcus epidermidis y Staphylococcus coagulasa negativa (SCN) resistentes a meticilina persisten en una proporción superior al 80%, mientras que han disminuido los S aureus resistentes a meticilina a menos del 40%. Conclusiones: El tratamiento empírico en situaciones de extrema gravedad se considera la cobertura de los patógenos más frecuentes como son los CGP-MR y los BGN y en situaciones especiales los hongos (AU)

Objective: In recent years, changes have occurred in the setting of bacteriemia related with the use of vascular catheters (BVC) and with the appearance of multiresistant gram positive cocci (MR-GPC), knowledge of the limitations regarding the antibiotics used most for their treatment (glycopeptides) and the appearance of new antibiotics active against these pathogens. This article analyzes the evolution of the rates, etiologies and markers of multiresistance of the most common pathogens in the BVC (including the primary bacteriemias) in the Spanish Intensive Medicine Departments (ICU). Material and methods: A multicenter, prospective, observational study of incidence, with voluntary participation, was conducted. A total of 74, 105, 112 and 121 ICUs belonging to 71, 97, 103 and 112 hospitals, respectively, collaborated including the years 2005-2008. The information included in the ENVIN-HELICS registry was used. Results: The rates of this complication have decreased and are now at about 5 episodes per 1,000 days of central venous catheter (CVC). One third of the episodes occur with significant systemic response (severe sepsis or septic shock). The MR-GPC were the most frequent, however Gram-negative bacilli (GNB) were identified in 30% of the cases and fungi (different species of Candida) in 6%. Staphylococcus epidermidis and coagulase-negative, methicillin-resistant staphylococci (CNS) persist in a proportion greater than 80%, while methicillin-resistance S. aureus have decreased to less than 40%. Conclusions: The empirical treatment in situations of extreme seriousness should consider coverage of the most frequent pathogens such as the MR-GPC and GNB and in special conditions, the fungi (AU)

[Epidemiology of the primary and vascular catheter-related bacteriemias in critical patients admitted to an Intensive Medicine Department]. / Epidemiología de las bacteriemias primarias y relacionadas con catéteres vasculares en pacientes críticos ingresados en servicios de medicina intensiva.

OBJECTIVE: In recent years, changes have occurred in the setting of bacteriemia related with the use of vascular catheters (BVC) and with the appearance of multiresistant gram positive cocci (MR-GPC), knowledge of the limitations regarding the antibiotics used most for their treatment (glycopeptides) and the appearance of new antibiotics active against these pathogens. This article analyzes the evolution of the rates, etiologies and markers of multiresistance of the most common pathogens in the BVC (including the primary bacteriemias) in the Spanish Intensive Medicine Departments (ICU). MATERIAL AND METHODS: A multicenter, prospective, observational study of incidence, with voluntary participation, was conducted. A total of 74, 105, 112 and 121 ICUs belonging to 71, 97, 103 and 112 hospitals, respectively, collaborated including the years 2005-2008. The information included in the ENVIN-HELICS registry was used. RESULTS: The rates of this complication have decreased and are now at about 5 episodes per 1,000 days of central venous catheter (CVC). One third of the episodes occur with significant systemic response (severe sepsis or septic shock). The MR-GPC were the most frequent, however Gram-negative bacilli (GNB) were identified in 30% of the cases and fungi (different species of Candida) in 6%. Staphylococcus epidermidis and coagulase-negative, methicillin-resistant staphylococci (CNS) persist in a proportion greater than 80%, while methicillin-resistance S. aureus have decreased to less than 40%. CONCLUSIONS: The empirical treatment in situations of extreme seriousness should consider coverage of the most frequent pathogens such as the MR-GPC and GNB and in special conditions, the fungi.

Estudio nacional de vigilancia de infección nosocomial en unidades de cuidados intensivos. Informe del año 2002 / National surveillance study of hospital- acquired infections in intensive care units. Report on the year 2002

Objetivo. Identificar las tasas nacionales de las infecciones hospitalarias adquiridas en Unidades de Cuidados Intensivos (UCI) relacionadas con instrumentalización, correspondientes al año 2002, así como conocer sus etiologías y la evolución de las resistencias de aquellos microorganismos más prevalentes. Diseño. Estudio de serie de casos, observacional y prospectivo. Ambito. 85 UCI, servicios o unidades de Cuidados Intensivos u otras unidades en donde se ingresan pacientes críticos, pertenecientes a 80 hospitales distintos. Pacientes y métodos. Se han incluido de forma continuada los pacientes ingresados durante más de 24 horas en las UCI participantes, que fueron seguidos hasta su alta de UCI o hasta un máximo de 30 días. Las infecciones objeto de vigilancia han sido: neumonías relacionadas con ventilación mecánica (N-VM), infecciones urinarias relacionadas con sonda uretral (IU-SU), bacteriemias primarias (BP) y relacionadas con catéteres vasculares (B-CVC) y bacteriemias secundarias. Resultados. Se han incluido 6.868 pacientes. En 684 (10%) pacientes se han detectado 1.019 infecciones, 445 N-VM (43,7%), 229 IU-SU (22,5%), 100 BP (9,8%), 135 B-CVC (13,2%) y 110 bacteriemias secundarias (10,8%). Las densidades de incidencia en relación con los días de exposición al factor de riesgo han sido 18,0 N-VM por 1.000 días de ventilación mecánica, 6,0 IU-SU por 1.000 días de sonda uretral y 4,5 BP-CVC por 1.000 días de catéter venoso central. La etiología predominante en las N-VM precoces ha sido Staphylococcus aureus sensible a meticilina y Haemophilus influenzae y en las N-VM tardías Pseudomonas aeruginosa y Acinetobacter baumannii. Las IU-SU han estado originadas predominantemente por Escherichia coli y Enterococcus faecalis y las BP-CVC por Staphylococcus epidermidis y Staphylococcus coagulasa negativo. Entre los marcadores de resistencia destacan por su frecuencia: P. aeruginosa resistente a imipenem-cilastatina (34,7%) y a ceftazidima (29,5%), S. aureus resistente a meticilina (35,3%), A. baumannii resistente a imipenem (33,9%) y E. coli resistente a ciprofloxacino (20,0%). No se ha detectado ninguna cepa de Enterococcus spp. o de Staphylococcus aureus resistente a vancomicina. Conclusiones. Se han identificado, para el año 2002, las tasas nacionales de las infecciones nosocomiales relacionadas con ventilación mecánica, sonda uretral y catéter venoso central, así como los agentes patógenos que predominan en cada una de ellas y el estado de los marcadores de multirresistencia

Objective. To identify national rates of hospital-acquired infections acquired in ICUs and related to instrumentalization, corresponding to the year 2002, as well as to define their etiologies and the evolution of the resistances of more prevalent microorganisms. Design. A study of cases series, observational and prospective.Context. Eighty five ICUs, Intensive Care Units departments, or other units where critical patients are admitted, from 80 different hospitals.Patients and methods. Patients included were consecutively admitted during more than 24 hours in the participating ICUs, with follow-up to their discharge of ICU or until 30 days post-admission. Infections evaluated were: respirator-associated pneumonias (RAM), urinary tract infections secondary to urethral catheter (UTI), primary bacteremias (PB) and bacteremias related to vascular catheters (BCVC), and secondary bacteremias. Results. 6,868 admitted patients were included. In 684 (10%) patients 1,019 infections were detected, 445 RAM (43.7%), 229 UTI (22.5%), 100 PB (9.8%), 135 BCVC (13.2%) and 110 secondary bacteremias (10.8%). The incidence-density with regard to the days of exposure to the risk factor were 18.0 RAM for 1,000 days of respirator, 6.0 UTI for 1,000 days of urethral catheter, and 4.5 BCVC for 1,000 days of central venous catheter. Predominant etiologies in early RAM were methicillin sensitive Staphylococcus aureus and Haemophilus influenzae, and in late RAM were Pseudomonas aeruginosa and Acinetobacter baumannii. Escherichia coli and Enterococcus faecalis were the predominant etiology in UTI, and Staphylococcus epidermidis and coagulase-negative Staphylococcus in BCVC. Among the resistance markers pointed out because of their frequency: P. aeruginosa resistant to imipenem-cilastatin (34.7%) and to ceftazidime (29.5%); S. aureus resistant to methicillin (35.3%); A. baumannii resistant to imipenem (33.9%), and E. coli resistant to ciprofloxacin (20.0%). No Enterococcus spp. or Staphylococcus aureus strains resistant to vancomycin were detected. Conclusions. In this study we have been identified for the year 2002 the national rates of hospital-acquired infections related to respirator, urethral catheter, and central venous catheter, as well as the pathogens that predominate in each one and the state of the markers of multiple resistance

[Diagnostic value of quantitative cultures of endotracheal aspirate in ventilator-associated pneumonia: a multicenter study]. / Valor diagnóstico del cultivo cuantitativo del aspirado endotraqueal en la neumonía adquirida durante la ventilación mecánica. Estudio multicéntrico.

OBJECTIVE: To study the validity of quantitative cultures of tracheal aspirate (TA) in comparison with the plugged telescoping catheter (PTC) for the diagnosis of mechanical ventilator-associated pneumonia. METHOD: Prospective multicenter study enrolling patients undergoing mechanical ventilation for longer than 72 hours. TA samples were collected from patients with suspected ventilator-associated pneumonia, followed by PTC sampling. Quantitative cultures were performed on all samples. Patients were classified according to the presence or not of pneumonia, based on clinical and radiologic criteria, clinical course and autopsy findings. The cutoff points were > or = 103 colony-forming units (cfu)/mL for PTC cultures; the TA cutoffs analyzed were > or = 105 and > or = 106 cfu/mL. RESULTS: Of the 120 patients studied, 84 had diagnoses of pneumonia and 36 did not (controls). The sensitivity values for TA > or = 106, TA > or = 105, and PTC, respectively, were 54% (95% confidence interval [CI], 42%-64%), 71% (95% CI, 60%-81%), and 68% (95% CI, 57%-78%). The specificity values were 75% (95% CI, 58%-88%), 58% (95% CI, 41%-74%), and 75% (95% CI, 58%-88%), respectively. Staphylococcus aureus was the microorganism most frequently isolated in both TA and PTC samples, followed in frequency by Pseudomomonas aeruginosa in TA samples and Haemophilus influenzae in PTC samples. No significant differences were found between the sensitivity of TA > or = 105 and that of PTC, nor between the specificities of TA > or = 106 and PTC. CONCLUSIONS: No differences in the specificities of PTC and TA were found when a TA cutoff of > or = 106 cfu/ml was used. Moreover, at a cutoff of > or = 105 the sensitivity of TA was not statistically different from that of PTC. Quantitative cultures of TA can be considered acceptable for the diagnosis of ventilator-associated pneumonia.

Valor diagnóstico del cultivo cuantitativo del aspirado endotraqueal en la neumonía adquirida durantela ventilación mecánica. Estudio multicéntrico / Diagnostic value of quantitative cultures of endotracheal aspirate in ventilator-associated pneumonia: a multicenter study

OBJETIVO: Estudiar la validez del aspirado traqueal (AT) con cultivos cuantitativos y compararla con el catéter telescopado (CTP) en el diagnóstico de la neumonía relacionada con la ventilación mecánica (NVM). MÉTODO: Estudio prospectivo y multicéntrico en el que se incluyó a pacientes sometidos a ventilación mecánica durante más de 72 h. A los pacientes con sospecha clínica de NVM se les realizaron AT y posteriormente CTP. A todas estas muestras se les practicó un cultivo cuantitativo. De acuerdo con criterios clínicos, radiológicos, de seguimiento y autópsicos se dividieron los pacientes en casos con neumonía y sin neumonía (controles). Se escogió como punto de corte para el CTP 103 unidades formadoras de colonias (ufc)/ml y para el AT se evaluó con 105 y > 106 ufc/ml, respectivamente. RESULTADOS: Se estudió a 120 pacientes; se consideró que 84 presentaban neumonía y 36 no la presentaban (controles). La sensibilidad fue del 54 por ciento (intervalo de confianza [IC] del 95 por ciento, 42-64 por ciento), el 71 por ciento (IC del 95 por ciento, 60-81 por ciento) y el 68 por ciento (IC del 95 por ciento, 57-78 por ciento) para AT 106, AT 105 y CTP, respectivamente. Las especificidades encontradas fueron del 75 por ciento (IC del 95 por ciento, 58 - 88 por ciento), el 58 por ciento (IC del 95 por ciento, 41-74 por ciento) y el 75 por ciento (IC del 95 por ciento, 58 -88 por ciento), respectivamente. El organismo aislado más frecuentemente fue Staphylococcus aureus tanto por AT como por CTP, seguido por Pseudomomonas aeruginosa en AT y por Haemophilus influenzae en CTP. No se encontraron diferencias significativas entre la sensibilidad del AT 105 y del CTP, y tampoco con las especificidades del AT 106 y el CTP. CONCLUSIONES: Cuando se utiliza un punto de corte de 106 ufc/ml o mayor para el AT en el diagnostico de la NVM se obtienen porcentajes de especificidad similares a los obtenidos con el CTP, y con el punto de corte 105 o mayor, porcentajes de sensibilidad aceptables. Los cultivos cuantitativos del AT pueden considerarse aceptables en el diagnóstico de la NVM (AU)

Influencia de la neumonía asociada a ventilación mecánica sobre la mortalidad de los pacientes críticos.¿Una historia interminable? / Influence of ventilator-associated pneumonia on mortality in critically-ill patients. A never-ending story?

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Efficacy and tolerability of piperacillin/tazobactam versus ceftazidime in association with amikacin for treating nosocomial pneumonia in intensive care patients: a prospective randomized multicenter trial.

OBJECTIVE: To compare clinical and bacteriological efficacy as well as tolerability of two regimens of broad-spectrum antibiotics (ceftazidime versus piperacillin/tazobactam) combined with amikacin in the treatment of nosocomial pneumonia in intensive care patients. DESIGN: Open label, prospective, multicenter, and randomized phase III clinical trial. SETTING: Medical or surgical intensive care units (ICUs) of nine acute-care teaching hospitals in Spain. PATIENTS AND PARTICIPANTS: One hundred and twenty-four ICU patients with nosocomial pneumonia and requiring mechanical ventilation were included. They were randomized to receive amikacin (15 mg/day divided into two doses) combined with either piperacillin (4 g every 6 h) and tazobactam (0.5 g every 6 h) (n = 88) or ceftazidime (2 g every 8 h) (n = 36). MEASUREMENTS AND RESULTS: The causative pathogen was determined in 60.2% of patients in the group of amikacin plus piperacillin/tazobactam and in 76.9% in the group of amikacin plus ceftazidime. A total of 94 bacterial organisms were isolated among which gram-negative bacilli predominated, Pseudomonas aeruginosa being the most frequent. Clinical response at the end of antibiotic therapy was considered satisfactory (cure and/or improvement) in 63.9% of patients in the amikacin plus piperacillin/tazobactam group and in 61.5% in the amikacin plus ceftazidime (odds ratio 1.1; 95% confidence interval 0.44-2.75). Eradication or presumptive eradication rates for each pathogen and for either gram-negative or gram-positive bacteria were similar in both antibiotic combinations (odds ratio 1.2; 95% confidence interval 0.39-3.66). A total of 21 adverse effects (23.9%) occurred in the amikacin plus piperacillin and tazobactam group and six (16.7%) in the amikacin plus ceftazidime group, thrombocytosis, renal dysfunction, and hepatic cytolysis being the most common. The efficacy and tolerability of the two therapeutic regimens were similar not only in the whole study population, but also in the subset of P. aeruginosa-related pneumonia (odds ratio 1; 95% confidence interval 0.08-13.37). CONCLUSIONS: Amikacin associated with either ceftazidime or piperacillin and tazobactam has shown comparable efficacy and tolerability in the treatment of ICU patients with nosocomial pneumonia.

[Pseudomembranous colitis in the elderly. Two case reports]. / Colitis pseudomembranosa en el anciano. A propósito de dos observaciones.

Two cases of Pseudomembranous Colitis are presented in old aged people with multi-systematic failure (renal, respiratory, cardiac) doing mention of favorable circumstances, of the clinic, of the physiopathological hypothesis of the diagnostic and therapeutical ways. They get to the conclusion of the easiness of the development in old people because of their precarious "vascularization" and the need of a systematic study of diarrhea in advanced ages, even though the picture seems simple.