Archive for June, 2013

HIV / SIDA IV CONSENSO ARGENTINO de Tratamiento Antirretroviral 2012 – SADI

Sociedad Argentina de Infectología (SADI)

Buenos Aires, Noviembre 2012

 

https://dl.dropboxusercontent.com/u/42385022/SADIconsenso%202012.pdf

June 30, 2013 at 5:32 pm

Extensive dissemination of methicillin-resistant Staphylococcus aureus (MRSA) between the hospital and the community in a country with a high prevalence of nosocomial MRSA.

PLoS One. 2013 Apr 3;8(4):e59960.

Espadinha D, Faria NA, Miragaia M, Lito LM, Melo-Cristino J, de Lencastre H; Médicos Sentinela Network.

Collaborators (9)

Source

Laboratory of Molecular Genetics, Instituto de Tecnologia Química e Biológica (ITQB), Oeiras, Portugal.

Abstract

According to the EARS-Net surveillance data, Portugal has the highest prevalence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) in Europe, but the information on MRSA in the community is very scarce and the links between the hospital and community are not known. In this study we aimed to understand the events associated to the recent sharp increase in MRSA frequency in Portugal and to evaluate how this has shaped MRSA epidemiology in the community. With this purpose, 180 nosocomial MRSA isolates recovered from infection in two time periods and 14 MRSA isolates recovered from 89 samples of skin and soft tissue infections (SSTI) were analyzed by pulsed-field gel electrophoresis (PFGE), staphylococcal chromosome cassette mec (SCCmec) typing, spa typing and multilocus sequence typing (MLST). All isolates were also screened for the presence of Panton Valentine leukocidin (PVL) and arginine catabolic mobile element (ACME) by PCR. The results showed that ST22-IVh, accounting for 72% of the nosocomial isolates, was the major clone circulating in the hospital in 2010, having replaced two previous dominant clones in 1993, the Iberian (ST247-I) and Portuguese (ST239-III variant) clones. Moreover in 2010, three clones belonging to CC5 (ST105-II, ST125-IVc and ST5-IVc) accounted for 20% of the isolates and may represent the beginning of new waves of MRSA in this hospital. Interestingly, more than half of the MRSA isolates (8/14) causing SSTI in people attending healthcare centers in Portugal belonged to the most predominant clones found in the hospital, namely ST22-IVh (n=4), ST5-IVc (n=2) and ST105-II (n=1). Other clones found included ST5-V (n=6) and ST8-VI (n=1). None of the MRSA isolates carried PVL and only five isolates (ST5-V-t179) carried ACME type II. The emergence and spread of EMRSA-15 may be associated to the observed increase in MRSA frequency in the hospital and the consequent spillover of MRSA into the community.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3617237/pdf/pone.0059960.pdf

June 27, 2013 at 3:54 pm

Screening Inpatients for MRSA — Case Closed

N Engl J Med 2013;368:2314-2315

EDITORIAL

Michael B. Edmond, M.D., M.P.H., and Richard P. Wenzel, M.D.

From the Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond.

One of the most controversial concepts in health care epidemiology during the past decade has been the active detection and isolation of patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization. The basic strategy is to screen inpatients for MRSA, typically with a polymerase-chain-reaction–based technology, in order to rapidly identify patients colonized with the organism and then initiate contact precautions (place them in a private room and require gowns and gloves on room entry). This approach has been used for decades to control outbreaks caused by epidemiologically important pathogens. As MRSA became endemic in hospitals, studies began to appear suggesting that active detection and isolation reduced health care–associated infections. However, the vast majority of the studies were single-center, observational, nonrandomized, before-and-after evaluations, which yielded low-quality evidence and precluded the establishment of causality. Nonetheless, most hospitals adopted programs of active detection and isolation, and nine states mandated MRSA screening of inpatients….

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMe1304831

June 27, 2013 at 3:51 pm

Infecciones producidas por Clostridium difficile

Enf Inf & Microb Clin Abril 2013 V.31  N04 P.254-63

Rodríguez-Pardo, Dolors; Mirelis, Beatriz; Navarro, Ferran

La epidemiologia de la infección por Clostridium difficile ha sufrido importantes cambios en la última década, tanto en Estados Unidos como en Europa, con un incremento del número y severidad de los casos, peor respuesta clínica a los tratamientos habituales y mayor porcentaje de recaídas. Estos cambios fueron atribuidos a la aparición y diseminación de una cepa epidémica conocida como cepa B1/NAP1/027 que se convirtió en endémica en determinadas áreas, aunque también han sido descritos otros clones epidémicos (pe: los pertenecientes al ribotipo 078). Ante esta situación, las guías de diagnóstico y tratamiento de la enfermedad han sido recientemente actualizadas y nuevos métodos diagnósticos han sido implementados. El objetivo de esta revisión es presentar una revisión sobre la situación actual de la infección producida por Clostridium difficile, su patogenia, los métodos diagnósticos existentes, las opciones de tratamiento y las medidas de prevención y control de casos.

PDF

http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=90197043&pident_usuario=0&pcontactid=&pident_revista=28&ty=15&accion=L&origen=elsevier&web=www.elsevier.es&lan=es&fichero=28v31n04a90197043pdf001.pdf

 

June 27, 2013 at 3:48 pm

Diagnóstico microbiológico de las infecciones intraabdominales

Enf Inf & Microb Clin Abril 2013 V.31  N04 P.230-9.

García-Sánchez, José Elías; García-García, M. Inmaculada; García-Garrote, Fernando; Sánchez-Romero, Isabel

Las infecciones intraabdominales constituyen un amplio y diverso grupo de procesos intra y retroperitoneales que incluyen infecciones no complicadas, en las que el proceso infeccioso se limita al órgano o tejido de origen (apendicitis, diverticulitis, colecistitis…), y complicadas, cuando la infección se extiende y afecta al peritoneo desencadenando cuadros generales, como las peritonitis difusas, o localizados, como los abscesos intraabdominales.

La mayoría se produce por perforación o inflamación de la pared intestinal, a partir de la flora gastrointestinal, y por tanto son infecciones polimicrobianas y mixtas, con predominio de bacterias anaerobias. El diagnóstico microbiológico es esencial para conocer la etiología y sobre todo la sensibilidad, en especial de las infecciones nosocomiales o comunitarias en pacientes de riesgo por el incremento de resistencia bacteriana, multirresistencia e implicación fúngica. A pesar de los avances en el diagnóstico microbiológico, en el caso de las infecciones intraabdominales sigue siendo directo, basándose en las tinciones y cultivos, y el progreso más notable es la introducción de la espectrometría de masas (MALDI-TOF) en la identificación de los patógenos implicados.

De forma general se indican las recomendaciones sobre la recogida, transporte y procesamiento microbiológico de las muestras clínicas. Se comenta la etiopatogenia, la clínica y el diagnóstico microbiológico de las peritonitis primarias, secundarias y terciarias y de la peritonitis (y otras infecciones) asociada a diálisis peritoneal, de los abscesos intraabdominales (intraperitoneales, viscerales y retroperitoneales), infecciones de las vías biliares, apendicitis y diverticulitis.

PDF

http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=90197041&pident_usuario=0&pcontactid=&pident_revista=28&ty=13&accion=L&origen=elsevier&web=www.elsevier.es&lan=es&fichero=28v31n04a90197041pdf001.pdf

June 27, 2013 at 3:47 pm

The Future of Antibiotics and Resistance

N Engl J Med. 2013 January 24; 368(4): 299–302.

Brad Spellberg, John G. Bartlett, David N. Gilbert

In its recent annual report on global risks, the World Economic Forum (WEF) concluded that “arguably the greatest risk … to human health comes in the form of antibiotic-resistant bacteria. We live in a bacterial world where we will never be able to stay ahead of the mutation curve. A test of our resilience is how far behind the curve we allow ourselves to fall.”

Traditional practices in infection control, antibiotic stewardship, and new antibiotic development are cornerstones of society’s approach to combating resistance and must be continued. But the WEF report underscores the facts that antibiotic resistance and the collapse of the antibiotic research- and-development pipeline continue to worsen despite our ongoing efforts on all these fronts. If we’re to develop countermeasures that have lasting effects, new ideas that complement traditional approaches will be needed.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3617123/pdf/nihms454543.pdf

June 27, 2013 at 3:44 pm

General Principles of Antimicrobial Therapy

Mayo Clin Proc. 2011 February; 86(2): 156–167

Surbhi Leekha, Christine L. Terrell, Randall S. Edson

Antimicrobial agents are some of the most widely, and often injudiciously, used therapeutic drugs worldwide. Important considerations when prescribing antimicrobial therapy include obtaining  an accurate diagnosis of infection; understanding the difference  between empiric and definitive therapy; identifying opportunities  to switch to narrow-spectrum, cost-effective oral agents for the  shortest duration necessary; understanding drug characteristics  that are peculiar to antimicrobial agents (such as pharmacodynamics and efficacy at the site of infection); accounting for  host characteristics that influence antimicrobial activity; and in  turn, recognizing the adverse effects of antimicrobial agents on  the host. It is also important to understand the importance of antimicrobial stewardship, to know when to consult infectious disease specialists for guidance, and to be able to identify situations when antimicrobial therapy is not needed. By following these general principles, all practicing physicians should be able to use antimicrobial agents in a responsible manner that benefits both the individual patient and the community.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/pdf/mayoclinproc_86_2_013.pdf

 

June 27, 2013 at 3:43 pm

Considerations when prescribing trimethoprim–sulfamethoxazole

CMAJ. 2011 November 8; 183(16): 1851–1858.

Joanne M.-W. Ho, David N. Juurlink

Introduced in 1968, trimethoprim–sulfamethoxazole remains a popular antibiotic because of its low cost, effectiveness and familiarity among clinicians. It is the most frequently prescribed antibiotic for urinary tract infections in Canada. Other indications include treatment of infections caused by Pneumocystis jiroveci, Toxoplasma gondii, Stenotrophomonas maltophilia and community-associated methicillin-resistant Staphylococcus aureus. In addition, among patients with depressed CD4 counts from infection with HIV, the use of low-dose trimethoprim–sulfamethoxazole for prophylaxis against P. jiroveci and T. gondii is associated with decreased mortality caused by opportunistic infections. With up to 4000 prescriptions for trimethoprim–sulfamethoxazole dispensed each week in Ontario, this drug is used by ……

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216436/pdf/1831851.pdf

June 27, 2013 at 3:41 pm

Clinical Findings in 111 Cases of Influenza A (H7N9) Virus Infection

N Engl J Med 2013;368:2277-2285

Hai-Nv Gao, M.D., Hong-Zhou Lu, M.D., Ph.D., Bin Cao, M.D., Bin Du, M.D., Hong Shang, M.D., Jian-He Gan, M.D., Shui-Hua Lu, M.D., Yi-Da Yang, M.D., Qiang Fang, M.D., Yin-Zhong Shen, M.D., Xiu-Ming Xi, M.D., Qin Gu, M.D., Xian-Mei Zhou, M.D., Hong-Ping Qu, M.D., Zheng Yan, M.D., Fang-Ming Li, M.D., Wei Zhao, M.D., Zhan-Cheng Gao, M.D., Guang-Fa Wang, M.D., Ling-Xiang Ruan, M.D., Wei-Hong Wang, M.D., Jun Ye, M.D., Hui-Fang Cao, M.D., Xing-Wang Li, M.D., Wen-Hong Zhang, M.D., Xu-Chen Fang, M.D., Jian He, M.D., Wei-Feng Liang, M.D., Juan Xie, M.D., Mei Zeng, M.D., Xian-Zheng Wu, M.D., Jun Li, M.D., Qi Xia, M.D., Zhao-Chen Jin, M.D., Qi Chen, M.D., Chao Tang, M.D., Zhi-Yong Zhang, M.D., Bao-Min Hou, M.D., Zhi-Xian Feng, M.D., Ji-Fang Sheng, M.D., Nan-Shan Zhong, M.D., and Lan-Juan Li, M.D.

BACKGROUND

During the spring of 2013, a novel avian-origin influenza A (H7N9) virus emerged and spread among humans in China. Data were lacking on the clinical characteristics of the infections caused by this virus.

METHODS

Using medical charts, we collected data on 111 patients with laboratory-confirmed avian-origin influenza A (H7N9) infection through May 10, 2013.

RESULTS

Of the 111 patients we studied, 76.6% were admitted to an intensive care unit (ICU), and 27.0% died. The median age was 61 years, and 42.3% were 65 years of age or older; 31.5% were female. A total of 61.3% of the patients had at least one underlying medical condition. Fever and cough were the most common presenting symptoms. On admission, 108 patients (97.3%) had findings consistent with pneumonia. Bilateral ground-glass opacities and consolidation were the typical radiologic findings. Lymphocytopenia was observed in 88.3% of patients, and thrombocytopenia in 73.0%. Treatment with antiviral drugs was initiated in 108 patients (97.3%) at a median of 7 days after the onset of illness. The median times from the onset of illness and from the initiation of antiviral therapy to a negative viral test result on real-time reverse-transcriptase–polymerase-chain-reaction assay were 11 days (interquartile range, 9 to 16) and 6 days (interquartile range, 4 to 7), respectively. Multivariate analysis revealed that the presence of a coexisting medical condition was the only independent risk factor for the acute respiratory distress syndrome (ARDS) (odds ratio, 3.42; 95% confidence interval, 1.21 to 9.70; P=0.02).

CONCLUSIONS

During the evaluation period, the novel H7N9 virus caused severe illness, including pneumonia and ARDS, with high rates of ICU admission and death. (Funded by the National Natural Science Foundation of China and others.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1305584

 

June 23, 2013 at 4:15 pm

Targeted versus Universal Decolonization to Prevent ICU Infection

N Engl J Med 2013;368:2255-2265

Susan S. Huang, M.D., M.P.H., Edward Septimus, M.D., Ken Kleinman, Sc.D., Julia Moody, M.S., Jason Hickok, M.B.A., R.N., Taliser R. Avery, M.S., Julie Lankiewicz, M.P.H., Adrijana Gombosev, B.S., Leah Terpstra, B.A., Fallon Hartford, M.S., Mary K. Hayden, M.D., John A. Jernigan, M.D., Robert A. Weinstein, M.D., Victoria J. Fraser, M.D., Katherine Haffenreffer, B.S., Eric Cui, B.S., Rebecca E. Kaganov, B.A., Karen Lolans, B.S., Jonathan B. Perlin, M.D., Ph.D., and Richard Platt, M.D. for the CDC Prevention Epicenters Program and the AHRQ DECIDE Network and Healthcare-Associated Infections Program

BACKGROUND

Both targeted decolonization and universal decolonization of patients in intensive care units (ICUs) are candidate strategies to prevent health care–associated infections, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

We conducted a pragmatic, cluster-randomized trial. Hospitals were randomly assigned to one of three strategies, with all adult ICUs in a given hospital assigned to the same strategy. Group 1 implemented MRSA screening and isolation; group 2, targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers); and group 3, universal decolonization (i.e., no screening, and decolonization of all patients). Proportional-hazards models were used to assess differences in infection reductions across the study groups, with clustering according to hospital.

RESULTS

A total of 43 hospitals (including 74 ICUs and 74,256 patients during the intervention period) underwent randomization. In the intervention period versus the baseline period, modeled hazard ratios for MRSA clinical isolates were 0.92 for screening and isolation (crude rate, 3.2 vs. 3.4 isolates per 1000 days), 0.75 for targeted decolonization (3.2 vs. 4.3 isolates per 1000 days), and 0.63 for universal decolonization (2.1 vs. 3.4 isolates per 1000 days) (P=0.01 for test of all groups being equal). In the intervention versus baseline periods, hazard ratios for bloodstream infection with any pathogen in the three groups were 0.99 (crude rate, 4.1 vs. 4.2 infections per 1000 days), 0.78 (3.7 vs. 4.8 infections per 1000 days), and 0.56 (3.6 vs. 6.1 infections per 1000 days), respectively (P<0.001 for test of all groups being equal). Universal decolonization resulted in a significantly greater reduction in the rate of all bloodstream infections than either targeted decolonization or screening and isolation. One bloodstream infection was prevented per 54 patients who underwent decolonization. The reductions in rates of MRSA bloodstream infection were similar to those of all bloodstream infections, but the difference was not significant. Adverse events, which occurred in 7 patients, were mild and related to chlorhexidine.

CONCLUSIONS

In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen. (Funded by the Agency for Healthcare Research and the Centers for Disease Control and Prevention; REDUCE MRSA ClinicalTrials.gov number, NCT00980980.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1207290

June 23, 2013 at 4:14 pm

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