Carbapenem alternatives for treatment of bloodstream infections due to AmpC producing enterobacterales.

INTRODUCTION: Carbapenems (CR) have traditionally been the first line treatment for bacteremia caused by AmpC-producing Enterobacterales. However, CR have a high ecological impact, and carbapenem-resistant strains continue rising. Thus, other treatment alternatives like Piperacillin-Tazobactam (P-T) or Cefepime (CEF) and oral sequential therapy (OST) are being evaluated. METHODS: We conducted a retrospective, single-centre observational study. All adult patients with AmpC-producing Enterobacterales bacteremia were included. The primary endpoint was clinical success defined as a composite of clinical cure, 14-day survival, and no adverse events. We evaluated the evolution of patients in whom OST was performed. RESULTS: Seventy-seven patients were included, 22 patients in the CR group and 55 in the P-T/CEF group (37 patients received CEF and 18 P-T). The mean age of the patients was higher in the P-T/CEF group (71 years in CR group vs. 76 years in P-T/CEF group, p = 0.053). In the multivariate analysis, age ≥ 70 years (OR 0.08, 95% CI [0.007-0.966], p = 0.047) and a Charlson index ≥ 3 (OR 0.16, 95% CI [0.026-0.984], p = 0.048), were associated with a lower clinical success. Treatment with P-T/CEF was associated with higher clinical success (OR 7.75, 95% CI [1.273-47.223], p = 0.026). OST was performed in 47% of patients. This was related with a shorter in-hospital stay (OST 14 days [7-22] vs. non-OST 18 days [13-38], p = 0.005) without difference in recurrence (OST 3% vs. non-OST 5%, p = 0.999). CONCLUSIONS: Targeted treatment with P-T/CEF and OST could be safe and effective treatments for patients with AmpC-producing Enterobacterales bacteremia.

Gastrointestinal colonization by OXA-48-producing Enterobacterales: risk factors for persistent carriage.

Carbapenem-resistant Enterobacterales (CRE) infections are a major health problem. Intestinal colonization is a key factor in developing infection. However, factors associated with persistent colonization by CRE are unknown. The aim of the study was to identify factors associated with persistent CRE gut colonization. This is a retrospective, single-centre, observational study of adult patients with CRE gut colonization between January 2015 and January 2020. Epidemiologic characteristics, comorbidities, infectious events, duration of hospitalization and antimicrobial treatment received in the follow-up period were collected. Colonization was defined as isolation in at least 2 rectal swab culture samples of CRE. Decolonization was defined as 3 negative rectal swab cultures or 2 negative cultures and a negative molecular test. A cohort of 86 patients with CRE gut colonization was selected: 44 patients with spontaneous decolonization (DC) and 42 patients with persistent colonization (PC). The mean follow-up period was 24 months (IQR 14-33) in the DC group vs. 25 months (IQR 16-36) in the PC group (p = 0.478). Patient characteristics were similar between both groups. Colonization by other MDR microorganisms was high (44 patients, 51%) and slightly more common in the PC group (PC 60% vs. DC 43%, p = 0.139). The use of ceftazidime-avibactam was more common among the PC group (PC 33% vs. DC 14%, p = 0.041). We observed a higher percentage of antimicrobial therapy in the previous 30 days (PC 68% vs. DC 57%, p = 0.371) and 90 days (PC 81% vs. DC 82%, p = 0.353) in the PC group. Multivariable analysis showed that patients that have received ceftazidime-avibactam therapy (OR 4.9 95% CI [1.45-16.39], p = 0.010), and those colonized by other MDR microorganisms (OR 2.5, 95% CI [0.96-6.25], p = 0.060) presented a higher risk of PC. Ceftazidime-avibactam use and colonization by other MDR microorganisms might be associated with CRE persistent gut colonization.

Ceftazidime-avibactam treatment in bacteremia caused by OXA-48 carbapenemase-producing Klebsiella pneumoniae.

Therapeutic options for bacteremia caused by carbapenem-resistant Enterobacterales (CRE) OXA-48-type are limited. The objective of this study was to analyze clinical success of CAZ-AVI compared with best available therapy (BAT) in patients with Klebsiella pneumoniae carbapenemase-producing OXA-48-type bacteremia (CRKp-OXA-48). We conducted a retrospective, single-center observational study in adult patients with CRKp-OXA-48 between December 2015 and May 2019. We collected the patients' clinical and epidemiological characteristics, antibiotic treatment (CAZ-AVI vs. BAT), and evolution. Factors associated with clinical success were analyzed using binary logistic regression. The study included 76 patients with CRKp-OXA-48-type bacteremia 33 received CAZ-AVI and 43 BAT. CAZ-AVI was mainly used in monotherapy (91%). Clinical success was more common in patients < 70-year-old (OR 4.79, 95% CI [1.435-16.002], p = 0.011) and CAZ-AVI treatment (OR 6.69, 95% CI [1.68-26.604], p = 0.007). Kaplan-Meier survival curve of 14-day mortality showed a lower mortality in patients who received CAZ-AVI (log rank 0.013). However, CAZ-AVI did not achieve statistical difference in IPTW for 14- and 30-day mortality (aOR 0.1, 95% CI [0.02-1.22], p = 0.076 and aOR 1.7, 95% CI [0.48-5.98], p = 0.413, respectively). CAZ-AVI treatment might be associated with a greater clinical success in CRKp-OXA-48 bacteremia.

[Expert opinion on strategies to improve vaccination coverage against seasonal influenza]. / Documento de opinión de expertos para la mejora de la cobertura vacunal frente a la gripe estacional.

Seasonal flu continues to be a major public health concern, and the influenza vaccine remains the most effective preventive measure. In Spain, vaccination coverage data from previous seasons show vaccination rates well below official targets; however, these figures improved significantly after the COVID-19 pandemic. Given the importance of achieving and maintaining high vaccination rates in order to avoid the clinical and economic impact of influenza, our multidisciplinary group of experts on vaccines analyzed the impact of low vaccination rates in Spain and drafted a series of measures to boost influenza vaccination coverage, particularly among priority groups.

Role of Pneumocystis jirovecii in patients with different pulmonary underlying condition using a nested-PCR.

OBJECTIVE: The prevalence of Pneumocystis jirovecii colonization and its role in pulmonary disease remains unclear. PCR methods have shown an improved sensitivity in the detection of this fungus. It has been suggested that the PCR results be combined with another test such as IFA to create a diagnostic algorithm. METHODS: A multiplex nested-PCR procedure with a 16S rRNA gene as the internal amplification control was evaluated to determine the role of P. jirovecii in pulmonary disease. RESULTS: A 20% of the 199 bronchoalveolar lavage samples were PCR-positive, 13.5% samples were PCR-inhibited, and the rate of Pneumocystis-colonisation was 6.4%. The sensitivity, specificity, positive predictive value and negative predictive value of the nested-PCR were 100%, 93%, 70% and 100%, respectively. The sensitivity of the nested-PCR was higher than the current "gold standard" immunofluorescence assay (IFA) (p< 0.0001). PCR-negative and PCR-positive patients did not show any clinical or radiological differences in the medical variables studied. CONCLUSIONS: PCR could help the diagnosis of Pneumocystis pulmonary disease given the high negative predictive value of the technique. P. jirovecii DNA can frequently be detected in healthy population, so the analysis of the patient medical history is critical to make the correct clinical decision.

Livedoid vasculopathy and recurrent thrombosis in a patient with lupus: seronegative antiphospholipid syndrome?

Livedoid vasculopathy is a rare condition which predominantly affects young women. It is characterized by intense painful purpuric maculae in the legs, ankles and feet, due to thrombosis of the small and medium-sized dermal vessels, in the absence of vasculitis. Livedoid vasculopathy has been frequently associated with hypercoagulable states and antiphospholipid syndrome. We describe a 34-year-old White woman suffering from systemic lupus erythematosus, livedo reticularis, haemolytic anaemia, severe thrombocytopenia and recurrent venous thrombosis who was admitted to the hospital for extremely painful purpuric lesions in her lower limbs. The clinical and histological findings were diagnostic of livedoid vasculopathy. Once the initial sub-therapeutic international normalized ratio levels were corrected, livedoid vasculopathy did not recur. Tests for antiphospholipid antibodies were repeatedly negative. This case, the first reported of livedoid vasculopathy in a patient with seronegative antiphospholipid syndrome and systemic lupus erythematosus, draws attention to livedoid vasculopathy, a thrombotic dermopathy that may be under-diagnosed in patients with antiphospholipid syndrome.

Late infection of an embolized renal graft presented as buttock cellulitis.

Graft intolerance syndrome (GIS) is a common complication developed in failed kidney allografts left in situ when the patients returned to hemodialysis. GIS usually develops within the first 6 months after immunosuppression has been withdrawn. When medical treatment has failed, transplantectomy is the conventional therapy. Nevertheless, in recent years, transvascular ethanol embolization has been reported as an effective, safe, and less invasive technique than transplantectomy for the management of patients with GIS. Although infrequent, the most severe complication is infection of the graft or surrounding tissues, which usually appears in the first weeks after the procedure. We present the first case of late infection of an embolized renal graft, more than 2 years after embolization.

El desempeño docente en el sistema tutoral del plan único de especialización en enfermería / Tutoring teaching performance in the unique plan of specialization in nursing

La evaluación de la práctica docente en el Sistema de enseñanza Tutoral del Plan Único de Especialización en Enfermería (PUEE), es una tarea sumamente compleja, que puede realizarse con diferentes enfoques por las diversas dimensiones que deben analizarse. Con esta investigación de corte descriptivo, observacional y transversal, se abordó el desarrollo de las actividades de los profesores que forman parte del Sistema de enseñanza Tutoral del PUEE, desde las experiencias y opiniones que manifestaron los 39 alumnos de la primera generación de egresados en 1998. Las opiniones de los alumnos de cinco de las especializaciones sobre las que se indagó (Enfermería del Adulto en Estado crítico; del Anciano; Cardiovascular e Infantil) son homogéneas entre sí, con una tendencia a calificar de parcial el cumplimiento de los objetivos de las diferentes modalidades de enseñanza que incluyen esta propuesta curricular. La excepción la constituye la especialidad en Salud Pública, cuyos estudiantes manifestaron mayor grado de satisfacción con el desarrollo del curso. Se destaca que la metodología y las técnicas de enseñanza de la mayoría de los tutores, son tradicionales y en opinión de los alumnos promueven el aprendizaje parcialmente. Esto nos hace pensar que será necesario contar con diversas estrategias de formación docente permanentes, ya que se trata de modificar esquemas muy arraigados respecto a las formas de enseñar Enfermería y la conceptualización del aprendizaje, tanto en el aula como en el entorno clínico. Esta investigación se concluyó en el año 2000.

The educational performance in the Tutoral System of Nursing Specialization Plan. The evaluation of educational practice int he Tutoral System of Nursing Specialization System of Nursing Plan (PUEE), is an extremely complex task, it con be realized by different approaches in diverse dimensions that must be analyzed. With this descritive cut, observacional and cross research, there was approached the development of the activities of the teachers who form a part of the PUEE, showing from the experiences and opinions. The opinion of the teachers who form a part of the PUEE, showing from the experiences and opinions. The opinion of the pupils of five of the specializations about thase who sere investigated (Nursing of the Adult in critical; Geriatric; Cardiovacular and Pediatric) are homogeneous amang them, with a trend to partially qualification of the fulfillment of the objetives of the different modalities of education, that includes this curricula. The exception is the Specialist in Public Health, which students demonstrated major degree of satisfaction with gools program. The methodology and education skills of mosto of the tutors, are traditional and in opinion of the pupils, they promote the partial learning, This makes us think that it will be necesary to apply diverse and permanent strategies of educational training, since it tries of modify schemes very established with regard to the ways of teaching showing nursing, and the learning conceptualization in the cassroom and in the clinical environment.

[Impact of an informative feedback process on drug prescription]. / Impacto de un proceso de feed-back informativo sobre la prescripción farmacéutica.

OBJECTIVE: To evaluate the impact of the face-to-face interview and feed-back on the prescribing habits of doctors interviewed. DESIGN: Controlled intervention study. SETTING: Primary Care area (PCA) of Alt Penedès-Garraf. PARTICIPANTS: 16 general practitioners (GP). The intervention group (IG) consisted of 8 GPs from the county of Garraf; the control group (CG), of 8 from the Alt Penedès. INTERVENTIONS: The target doctors were identified by quantitative analysis of GP prescription in the PCA in 1993. In June 1994, there was a face-to-face interview with the IG doctors. There was no intervention on the CG. MEASUREMENTS AND MAIN RESULTS: No statistically significant differences were found, for the overall prescription turnover or expenditure generated by the prescriptions, between the two groups in the pre-intervention period (p > 0.05). Drugs expenditure decreased in the IG versus an increase in the CG. Comparison of the monthly accumulated increase revealed containment of drugs expenditure during the 9 months after the interview in the IG against the growth in the CG. In addition the number of units of medicine of doubtful efficacy (UDE) and unwarranted combinations of medicine to combat infection (UCMI) prescribed per doctor went down in the IG, but went up in the CG. CONCLUSIONS: The results show a containment in the growth of drug expenditure and a decrease in UDE and UCMI prescription by GPs in the IG as against the CG. The decreasing effectiveness over time of the one-off intervention suggests that there should be regular interventions to ensure a long-term effect.

[Criteria for the development of a formulary of drugs in a basic health area and impact on prescription]. / Criterios de elaboración de un formulario de medicamentos en un área básica de salud e impacto sobre la prescripción.

OBJECTIVE: To promote rational prescription in Primary Care by elaborating a restricted list of medicines in a PC, the implementation of the list and the evaluation of its influence. DESIGN: Controlled intervention study. SETTING: Intervention group: Castelldefels Health Centre. CONTROL GROUP: Molí Nou HC in same health sector. PARTICIPANTS: Doctors from the PC teams of both centres. INTERVENTIONS: Initially the prescription for 1992 of the intervention group was analysed. The main therapeutic groups prescribed for on the initiative of the General Practitioners (GP) of the Castelldefels HC were identified and the intervention was then carried out on them. The PC team from the intervention group, chose the drugs by consensus, on the basis of pharmaceutical advice. MEASUREMENTS AND MAIN RESULTS: Castelldefels HD presented worse indicators than the rest of the Sector's. It was observed that the GPs decided 63.4% +/- 3.9% of their therapeutic prescriptions. The groups most prescribed for on GP initiative were systemic (J) and respiratory apparatus (R) anti-infection therapies. The intervention was verified with Macrolids, Beta-lactamics (excluding Cephalosporins) and Quinolones. In neither of the two HDs were statistically significant differences (p < 0.05) in the consumption of the selected antibiotics between the two periods observed. CONCLUSIONS: This process is aimed at altering GPs' attitudes, it is essential that they participate in the choice of medicines in order to keep them involved; and that the ongoing records of the chosen drugs are verified, with the evaluation of their influence then being just one more tool in this process.