Archive for March 19, 2016

DENGUE – GUIA para el Equipo de Salud – DICIEMBRE 2015

Ministerio Salud Nación de Argentina DIC. 2015 4ta Edición

 

Contenido:

Información para el equipo de salud

  1. Introducción
  2. Manifestaciones clínicas
  3. ¿Cuándo sospechar dengue?
  4. ¿Cómo se clasifica el caso sospechoso de dengue?
  5. ¿Cómo se confirma el dengue?
  6. ¿Cómo se trata el paciente con dengue?
  7. Flujograma de manejo de casos sospechosos
  8. ¿Qué se debe hacer si se confirma caso sospechoso de dengue?
  9. ¿Cómo notificar el caso de dengue?
  10. Prevención de dengue en la familia y la comunidad

 

Recomendaciones para la organización de las actividades en el Equipo de Salud

  1. ¿Qué pueden Ud. y su equipo de salud hacer para contribuir al control del dengue en su área?

 

Información para la población

  1. ¿Qué es el dengue?
  2. ¿Cómo se contagia?
  3. ¿Qué puedo hacer para prevenir el dengue?
  4. ¿Cómo puedo saber si tengo dengue?
  5. ¿Hay algún tratamiento?

 

Anexos

  1. Dengue perinatal
  2. Hemocomponentes
  3. Solución Polielectrolítica
  4. Diagnóstico diferencial del dengue
  5. Ficha de Notificación de Síndrome Febril Inespecífico
  6. Vacuna dengue

 

PDF

http://www.msal.gob.ar/images/stories/bes/graficos/0000000062cnt-guia-dengue-2016.pdf

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March 19, 2016 at 10:00 pm

Effectiveness of Practices To Increase Timeliness of Providing Targeted Therapy for Inpatients with Bloodstream Infections: a Laboratory Medicine Best Practices Systematic Review and Meta-analysis

Clinical Microbiology Reviews January 2016  V.29 N.1 P.59-103

Stephanie S. Buehler, Bereneice Madison, Susan R. Snyder, James H. Derzon, Nancy E. Cornish, Michael A. Saubolle, Alice S. Weissfeld, Melvin P. Weinstein, Edward B. Liebow, and Donna M. Wolk

aBattelle Center for Analytics and Public Health, Atlanta, Georgia, USA

bCenters for Disease Control and Prevention, Center for Surveillance, Epidemiology and Laboratory Services (CSELS), Atlanta, Georgia, USA

cBanner Good Samaritan Medical Center, Banner Health, Phoenix, Arizona, USA, and University of Arizona College of Medicine, Phoenix, and University of Arizona College of Medicine, Tucson, Arizona, USA

dMicrobiology Specialists Incorporated, Houston, Texas, USA

eRutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA

fGeisinger Health System, Danville, Pennsylvania, USA

Background.

Bloodstream infection (BSI) is a major cause of morbidity and mortality throughout the world. Rapid identification of bloodstream pathogens is a laboratory practice that supports strategies for rapid transition to direct targeted therapy by providing for timely and effective patient care. In fact, the more rapidly that appropriate antimicrobials are prescribed, the lower the mortality for patients with sepsis. Rapid identification methods may have multiple positive impacts on patient outcomes, including reductions in mortality, morbidity, hospital lengths of stay, and antibiotic use. In addition, the strategy can reduce the cost of care for patients with BSIs.

Objectives.

The purpose of this review is to evaluate the evidence for the effectiveness of three rapid diagnostic practices in decreasing the time to targeted therapy for hospitalized patients with BSIs. The review was performed by applying the Centers for Disease Control and Prevention’s (CDC’s) Laboratory Medicine Best Practices Initiative (LMBP) systematic review methods for quality improvement (QI) practices and translating the results into evidence-based guidance (R. H. Christenson et al., Clin Chem 57:816–825, 2011, http://dx.doi.org/10.1373/clinchem.2010.157131).

Search strategy.

A comprehensive literature search was conducted to identify studies with measurable outcomes. A search of three electronic bibliographic databases (PubMed, Embase, and CINAHL), databases containing “gray” literature (unpublished academic, government, or industry evidence not governed by commercial publishing) (CIHI, NIHR, SIGN, and other databases), and the Cochrane database for English-language articles published between 1990 and 2011 was conducted in July 2011.

Dates of search.

The dates of our search were from 1990 to July 2011.

Selection criteria.

Animal studies and non-English publications were excluded. The search contained the following medical subject headings: bacteremia; bloodstream infection; time factors; health care costs; length of stay; morbidity; mortality; antimicrobial therapy; rapid molecular techniques, polymerase chain reaction (PCR); in situ hybridization, fluorescence; treatment outcome; drug therapy; patient care team; pharmacy service, hospital; hospital information systems; Gram stain; pharmacy service; and spectrometry, mass, matrix-assisted laser desorption-ionization. Phenotypic as well as the following key words were searched: targeted therapy; rapid identification; rapid; Gram positive; Gram negative; reduce(ed); cost(s); pneumoslide; PBP2; tube coagulase; matrix-assisted laser desorption/ionization time of flight; MALDI TOF; blood culture; EMR; electronic reporting; call to provider; collaboration; pharmacy; laboratory; bacteria; yeast; ICU; and others. In addition to the electronic search being performed, a request for unpublished quality improvement data was made to the clinical laboratory community.

Main results.

Rapid molecular testing with direct communication significantly improves timeliness compared to standard testing. Rapid phenotypic techniques with direct communication likely improve the timeliness of targeted therapy. Studies show a significant and homogeneous reduction in mortality associated with rapid molecular testing combined with direct communication.

Authors’ conclusions.

No recommendation is made for or against the use of the three assessed practices of this review due to insufficient evidence. The overall strength of evidence is suggestive; the data suggest that each of these three practices has the potential to improve the time required to initiate targeted therapy and possibly improve other patient outcomes, such as mortality. The meta-analysis results suggest that the implementation of any of the three practices may be more effective at increasing timeliness to targeted therapy than routine microbiology techniques for identification of the microorganisms causing BSIs. Based on the included studies, results for all three practices appear applicable across multiple microorganisms, including methicillin-resistant Staphylococcus aureus (MRSA), methicillin-sensitive S. aureus (MSSA), Candida species, and Enterococcus species.

PDF

http://cmr.asm.org/content/29/1/59.full.pdf

March 19, 2016 at 9:31 pm

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis.

Health Technol Assess. 2015 Nov;19(96):v-xxv, 1-236.

Westwood M1, Ramaekers B2, Whiting P1, Tomini F2, Joore M2, Armstrong N1, Ryder S1, Stirk L1, Severens J3, Kleijnen J2.

Author information

1Kleijnen Systematic Reviews Ltd, York, UK.

2Maastricht University Medical Centre, Maastricht, The Netherlands.

3Erasmus University Rotterdam, Rotterdam, The Netherlands.

Abstract

BACKGROUND:

Determination of the presence or absence of bacterial infection is important to guide appropriate therapy and reduce antibiotic exposure. Procalcitonin (PCT) is an inflammatory marker that has been suggested as a marker for bacterial infection.

OBJECTIVES:

To assess the clinical effectiveness and cost-effectiveness of adding PCT testing to the information used to guide antibiotic therapy in adults and children (1) with confirmed or highly suspected sepsis in intensive care and (2) presenting to the emergency department (ED) with suspected bacterial infection.

METHODS:

Twelve databases were searched to June 2014. Randomised controlled trials were assessed for quality using the Cochrane Risk of Bias tool. Summary relative risks (RRs) and weighted mean differences (WMDs) were estimated using random-effects models. Heterogeneity was assessed visually using forest plots and statistically using the I (2) and Q statistics and investigated through subgroup analysis. The cost-effectiveness of PCT testing in addition to current clinical practice was compared with current clinical practice using a decision tree with a 6 months’ time horizon.

RESULTS:

Eighteen studies (36 reports) were included in the systematic review. PCT algorithms were associated with reduced antibiotic duration [WMD -3.19 days, 95% confidence interval (CI) -5.44 to -0.95 days, I (2) = 95.2%; four studies], hospital stay (WMD -3.85 days, 95% CI -6.78 to -0.92 days, I (2) = 75.2%; four studies) and a trend towards reduced intensive care unit (ICU) stay (WMD -2.03 days, 95% CI -4.19 to 0.13 days, I (2) = 81.0%; four studies). There were no differences for adverse clinical outcomes. PCT algorithms were associated with a reduction in the proportion of adults (RR 0.77, 95% CI 0.68 to 0.87; seven studies) and children (RR 0.86, 95% CI 0.80 to 0.93) receiving antibiotics, reduced antibiotic duration (two studies). There were no differences for adverse clinical outcomes. All but one of the studies in the ED were conducted in people presenting with respiratory symptoms. Cost-effectiveness: the base-case analyses indicated that PCT testing was cost-saving for (1) adults with confirmed or highly suspected sepsis in an ICU setting; (2) adults with suspected bacterial infection presenting to the ED; and (3) children with suspected bacterial infection presenting to the ED. Cost-savings ranged from £368 to £3268. Moreover, PCT-guided treatment resulted in a small quality-adjusted life-year (QALY) gain (ranging between < 0.001 and 0.005). Cost-effectiveness acceptability curves showed that PCT-guided treatment has a probability of ≥ 84% of being cost-effective for all settings and populations considered (at willingness-to-pay thresholds of £20,000 and £30,000 per QALY).

CONCLUSIONS:

The limited available data suggest that PCT testing may be effective and cost-effective when used to guide discontinuation of antibiotics in adults being treated for suspected or confirmed sepsis in ICU settings and initiation of antibiotics in adults presenting to the ED with respiratory symptoms and suspected bacterial infection. However, it is not clear that observed costs and effects are directly attributable to PCT testing, are generalisable outside people presenting with respiratory symptoms (for the ED setting) and would be reproducible in the UK NHS. Further studies are needed to assess the effectiveness of adding PCT algorithms to the information used to guide antibiotic treatment in children with suspected or confirmed sepsis in ICU settings. Additional research is needed to examine whether the outcomes presented in this report are fully generalisable to the UK.

PDF

http://www.ncbi.nlm.nih.gov/books/NBK327098/pdf/Bookshelf_NBK327098.pdf

March 19, 2016 at 9:28 pm

Procalcitonin to guide antibiotic therapy in the ICU.

Int J Antimicrob Agents. 2015 Dec;46 Suppl 1:S19-24.

Bréchot N1, Hékimian G2, Chastre J2, Luyt CE2.

Author information

1Service de Réanimation Médicale, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique – Hôpitaux de Paris, Université Pierre-et-Marie-Curie, Paris 6, 47 boulevard de l’Hôpital, 75651 Paris Cedex 13, France; INSERM U1050, Centre interdisciplinaire de recherche en biologie – College de France, 11 Place Marcelin Berthelot, 75231 Paris Cedex 05, France. Electronic address: nicolas.brechot@aphp.fr

2Service de Réanimation Médicale, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique – Hôpitaux de Paris, Université Pierre-et-Marie-Curie, Paris 6, 47 boulevard de l’Hôpital, 75651 Paris Cedex 13, France; INSERM, UMRS-1166, Institute of Cardiometabolism and Nutrition (iCAN), Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris 6, 47 bd de l’Hôpital, 75651 Paris Cedex 13, France.

Abstract

The serum procalcitonin (PCT) concentration reflects both the systemic response to bacterial infection and its severity. However, its accuracy in distinguishing intensive care unit (ICU) patients with and without infection remains low owing to a lack of specificity and the time lapse between infection onset and the PCT rise.

Hence, PCT cannot be used as a marker to start or withhold antibiotic therapy for ICU patients.

However, the kinetics of the PCT concentration decrease under antibiotic therapy can adequately monitor infection evolution with therapy and can help to customise antibiotic duration.

PCT-guided algorithms to guide antibiotic discontinuation were able to shorten antibiotic duration without impacting patient outcomes in several multicentre randomised studies.

Notably, antibiotics can be stopped very early when PCT is low and remains low as this indicates that bacterial infection is unlikely.

When PCT falls to <0.5ng/mL or >80% from its peak value, antibiotics for non-localised infections can safely be stopped.

PDF

http://www.ijaaonline.com/article/S0924-8579(15)00361-1/pdf

March 19, 2016 at 1:47 pm

Antimicrobial stewardship in the intensive care setting–a review and critical appraisal of the literature.

Swiss Med Wkly. 2015 Dec 21;145:w14220.

Mertz D1, Brooks A2, Irfan N3, Sung M2.

Author information

1Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada;

2Department of Medicine, McMaster University, Hamilton, ON, Canada; Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada.

3Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada.

Abstract

BACKGROUND:

Many antimicrobial stewardship programmes (ASPs) target the intensive care unit owing to high antimicrobial utilisation. In this review, we summarise and assess the quality of evidence supporting the implementation of various ASP strategies in the intensive care unit setting with a focus on publications between 2010 and 2015.

METHODS:

We searched Medline up to April 2015 and screened publications of interest for additional relevant articles. We grouped the strategies into four categories: audit and feedback, formulary restrictions, guidelines/clinical pathways, and procalcitonin. We used GRADE terminology to describe the quality of evidence.

RESULTS AND CONCLUSIONS:

We identified several studies reporting optimisation and reduction of antibiotic utilisation as well as cost reduction in all four strategies. Randomised controlled trials reviewing the role of procalcitonin demonstrate a moderate level of evidence. Given the lack of randomised controlled trials to support the role of guidelines, formulary restrictions, and audit and feedback, the level of evidence supporting these strategies is low. Importantly, there is no convincing evidence to support the main goal of ASP, namely to improve patient outcomes. Larger, rigorous long-term studies using a cluster randomised controlled trial or at least a controlled quasi-experimental design with time series are required to assess the impact of ASP on patient-important outcomes and on the emergence of resistance in the intensive care unit setting.

PDF (CLIC IN PDF)

March 19, 2016 at 1:45 pm

Ventilator-associated pneumonia in critically ill patients with intensive antibiotic usage.

Pak J Med Sci. 2015 Nov-Dec;31(6):1441-6.

Bor C1, Demirag K2, Okcu O3, Cankayali I4, Uyar M5.

Author information

1Canan Bor, Department of Anaesthesiology and Intensive Care Unit, Ege University School of Medicine Hospital, Izmir, Turkey.

2Kubilay Demirag, Department of Anaesthesiology and Intensive Care Unit, Ege University School of Medicine Hospital, Izmir, Turkey.

3Ozlem Okcu, Department of Radiology, Ege University School of Medicine Hospital, Izmir, Turkey.

4Ilkin Cankayali, Department of Anaesthesiology and Intensive Care Unit, Ege University School of Medicine Hospital, Izmir, Turkey.

5Mehmet Uyar, Department of Anaesthesiology and Intensive Care Unit, Ege University School of Medicine Hospital, Izmir, Turkey.

Abstract

OBJECTIVE:

Ventilator-associated pneumonia (VAP) is an infection with high mortality and morbidity that prolongs the length of stay in the intensive care unit (ICU) and hospitalisation. VAP is one of the most common infections in critically ill patients. This study aimed to prospectively determine the VAP rate and associated factors in critically ill patients with intensive antibiotic usage during a one-year period.

METHODS:

In total, 125 out of 360 patients admitted to the intensive care unit during the one-year study period (September 2010-2011) were included for follow-up for VAP diagnosis. Demographic data, APACHE II scores, diagnoses on admission, clinical pulmonary infection scores (CPIS), CRP, procalcitonin, risk factors for infection, time to VAP diagnosis, and bacteriological culture results were recorded. All data were assessed in terms of ICU, hospital and 28-day mortality.

RESULTS:

In total, 56 (45%) out of 125 patients were diagnosed with VAP. In addition, 91% of patients diagnosed with VAP were administered antibiotics before diagnosis. In the VAP patients, the mortality rates were 48, 68 and 71% for 28-day, ICU and hospital mortality, respectively.

CONCLUSION:

The coexistence of clinical and microbiological parameters should not be sought when diagnosing VAP in patients who use antibiotics intensively. VAP can be diagnosed when CPIS≤6 in cases with sufficient microbiological evidence. This strategy may decrease mortality by preventing a delay in therapy.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4744297/pdf/PJMS-31-1441.pdf

March 19, 2016 at 1:43 pm

Comparative Study of Plasma Endotoxin with Procalcitonin Levels in Diagnosis of Bacteremia in Intensive Care Unit Patients.

Chin Med J (Engl). 2016 20th Feb;129(4):417-423.

Wang T, Cui YL, Lin ZF, Chen DC1.

Author information

1Department of Emergency Medicine, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.

Abstract

BACKGROUND:

Both procalcitonin (PCT) and plasma endotoxin levels cannot be solely used for a definite diagnosis of bacteremia or sepsis, and there has been few study comparing the values of the two biomarkers for the diagnosis of bacteremia. The aim of this study was to identify bacteria causing bacteremia and evaluate the role of the two biomarkers in the diagnosis of bacteremia in Intensive Care Unit (ICU).

METHODS:

The medical records of 420 patients in ICU were retrospectively reviewed. Patients (n = 241) who met the inclusion criteria were subjected to blood culture (BC) for the analysis of the endotoxin or PCT levels. The exclusion criteria included the presence of infection with human immunodeficiency virus and/or AIDS, neutropenia without sepsis, pregnancy, treatment with immunosuppressive therapies, or blood diseases such as hematological tumors. Patients’ BC episodes were divided into BC negative, Gram-negative (GN) bacteria, Gram-positive bacteria, and fungi groups. The PCT and plasma endotoxin levels were compared in the different groups.

RESULTS:

A total of 241 patients with 505 episodes of BC were analyzed. The GN bacteria group showed higher levels of PCT and endotoxin than the BC negative, Gram-positive bacteria, and fungi groups. GN bacteremia was more prevalent than Gram-positive bacteremia. The GN bacteremia caused by non-Enterobacteriaceae infection presented higher endotoxin level than that by Enterobacteriaceae, but no significant difference in PCT levels was observed between the two groups. The plasma endotoxin significantly differed among different groups and was bacterial species dependent.

CONCLUSIONS:

Plasma endotoxin was more related to GN than to Gram-positive bacteremia, and that endotoxin level was species dependent, but PCT level remained relatively more stable within the GN bacteria caused bacteremia. Both GN and positive bacteria caused bacteremia in the ICU patients in different regions of China. And PCT is a more valuable biomarker than endotoxin in the diagnosis of bacteremia.

PDF

http://www.cmj.org/temp/ChinMedJ1294417-4226579_114425.pdf

 

March 19, 2016 at 1:41 pm

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