Posts filed under ‘Epidemiología’

A Review of Combination Antimicrobial Therapy for Enterococcus faecalis Bloodstream Infections and Infective Endocarditis

Clinical Infectious Diseases July 15, 2018 V.67 N.2 P.303-309

EDITOR’S CHOICE

Maya Beganovic; Megan K Luther; Louis B Rice; Cesar A Arias; Michael J Rybak …

Esta revisión destaca las opciones de tratamiento disponibles y sus limitaciones, y proporciona orientación para futuros esfuerzos de investigación para ayudar en el tratamiento de infecciones graves de Enterococcus faecalis, a saber, endocarditis infecciosa.

FULL TEXT

https://academic.oup.com/cid/article/67/2/303/4829420

PDF (CLIC en PDF)

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July 15, 2018 at 5:04 pm

Antimicrobial-Resistant Klebsiella pneumoniae Carriage and Infection in Specialized Geriatric Care Wards Linked to Acquisition in the Referring Hospital

Clinical Infectious Diseases July 15, 2018 V.67 N.2 P.161-170

Claire L Gorrie; Mirjana Mirceta; Ryan R Wick; Louise M Judd; Kelly L Wyres …

La microbiota intestinal del paciente fue la fuente principal de Klebsiella pneumoniae, pero las cepas de β-lactamasa de espectro extendido (BLEE) se adquirieron en el hospital de referencia. Esto resalta el potencial para la detección ó screening rectal y la importancia de una red hospitalaria más amplia para el manejo local del riesgo.

Background

Klebsiella pneumoniae is a leading cause of extended-spectrum β-lactamase (ESBL)–producing hospital-associated infections, for which elderly patients are at increased risk.

Methods

We conducted a 1-year prospective cohort study, in which a third of patients admitted to 2 geriatric wards in a specialized hospital were recruited and screened for carriage of K. pneumoniae by microbiological culture. Clinical isolates were monitored via the hospital laboratory. Colonizing and clinical isolates were subjected to whole-genome sequencing and antimicrobial susceptibility testing.

Results

K. pneumoniae throat carriage prevalence was 4.1%, rectal carriage 10.8%, and ESBL carriage 1.7%, and the incidence of K. pneumoniae infection was 1.2%. The isolates were diverse, and most patients were colonized or infected with a unique phylogenetic lineage, with no evidence of transmission in the wards. ESBL strains carried blaCTX-M-15 and belonged to clones associated with hospital-acquired ESBL infections in other countries (sequence type [ST] 29, ST323, and ST340). One also carried the carbapenemase blaIMP-26. Genomic and epidemiological data provided evidence that ESBL strains were acquired in the referring hospital. Nanopore sequencing also identified strain-to-strain transmission of a blaCTX-M-15 FIBK/FIIK plasmid in the referring hospital.

Conclusions

The data suggest the major source of K. pneumoniae was the patient’s own gut microbiome, but ESBL strains were acquired in the referring hospital. This highlights the importance of the wider hospital network to understanding K. pneumoniae risk and infection prevention. Rectal screening for ESBL organisms on admission to geriatric wards could help inform patient management and infection control in such facilities.

FULL TEXT

https://academic.oup.com/cid/article/67/2/161/4798841

PDF /CLIC en PDF)

July 15, 2018 at 5:01 pm

JULY 2018 – Pyogenic Arthritis of the Fingers and the Wrist: Can We Shorten Antimicrobial Treatment Duration?

Background.

Pyogenic arthritis of the small joints of the hand and wrist is a known but poorly described entity. The objective of this work was to characterize the clinical presentation, antimicrobial treatment, and surgical interventions of native small joint arthritis (SJA) treated in our tertiary center.

Methods.

According to predefined variables, medical records of adult patients with SJA treated in a Swiss university hospital between 2005 and 2013 were retrospectively analyzed.

Results.

The median age of 97 patients (101 joints) was 52 years (interquartile range [IQR], 38–68 years); 52% had no comorbidity. Small joint arthritis of the second and third fingers accounted for 53% of infections, with metacarpal-phalangeal and proximal interphalangeal joints most commonly involved. Of 86 (89%) episodes with an exogenous source, 63 (65%) followed a trauma. The most commonly isolated microorganism was Staphylococcus aureus (38%), followed by β-hemolytic streptococci (13%) and Pasteurella spp (11%). Eighty-seven episodes (89 joints) in patients with follow-up examinations were included in treatment and outcome analyses. Up to 2 surgical interventions were required to cure infection in 74 (83%) joints. Median antimicrobial treatment duration was 14 days (IQR, 12–28 days), with amoxicillin/clavulanate administered in 74 (85%) episodes. At follow up, cure of infection was noted in all episodes and good functional outcome in 79% of episodes.

Conclusions.

Small joint arthritis shows considerable differences from clinical patterns reported for larger joints. In our

series, the outcome was good with no more than 2 surgical interventions and median treatment duration of 14 days in 79% of episodes.

FULL TEXT

https://academic.oup.com/ofid/article/4/2/ofx058/3090339

PDF (CLIC en DF)

July 15, 2018 at 4:05 pm

JULY 2018 – Risk Factors for Surgical Site Infection After Cholecystectomy

Background.

There are limited data on risk factors for surgical site infection (SSI) after open or laparoscopic cholecystectomy.

Methods.

A retrospective cohort of commercially insured persons aged 18–64 years was assembled using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition codes for cholecystectomy from December 31, 2004 to December 31, 2010. Complex procedures and patients (eg, cancer, end-stage renal disease) and procedures with pre-existing infection were excluded. Surgical site infections within 90 days after cholecystectomy were identified by ICD-9-CM diagnosis codes. A Cox proportional hazards model was used to identify independent risk factors for SSI.

Results.

Surgical site infections were identified after 472 of 66566 (0.71%) cholecystectomies; incidence was higher after open (n = 51, 4.93%) versus laparoscopic procedures (n = 421, 0.64%; P < .001). Independent risk factors for SSI included male gender, preoperative chronic anemia, diabetes, drug abuse, malnutrition/weight loss, obesity, smoking-related diseases, previous Staphylococcus aureus infection, laparoscopic approach with acute cholecystitis/obstruction (hazards ratio [HR], 1.58; 95% confidence interval [CI], 1.27–1.96), open approach with (HR, 4.29; 95% CI, 2.45–7.52) or without acute cholecystitis/obstruction (HR, 4.04; 95% CI, 1.96–8.34), conversion to open approach with (HR, 4.71; 95% CI, 2.74–8.10) or without acute cholecystitis/obstruction (HR, 7.11; 95% CI, 3.87–13.08), bile duct exploration, postoperative chronic anemia, and postoperative pneumonia or urinary tract infection.

Conclusions.

Acute cholecystitis or obstruction was associated with significantly increased risk of SSI with laparoscopic but not open cholecystectomy. The risk of SSI was similar for planned open and converted procedures. These findings suggest that stratification by operative factors is important when comparing SSI rates between facilities.

FULL TEXT

https://academic.oup.com/ofid/article/4/2/ofx036/3044173

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July 15, 2018 at 4:00 pm

July 2018 Comparative Sensitivity of Transthoracic and Transesophageal Echocardiography in Diagnosis of Infective Endocarditis Among Veterans With Staphylococcus aureus Bacteremia

Background

Echocardiography is fundamental for diagnosing infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB), but whether all such patients require transesophageal echocardiography (TEE) is controversial.

Methods.

We identified SAB cases between February 2008 and April 2012. We compared sensitivity and specificity of transthoracic echocardiography (TTE) and TEE for evidence of IE, and we determined impacts of IE risk factors and TTE image quality on comparative sensitivities of TTE and TEE and their impact on clinical decision making.

Results.

Of 215 evaluable SAB cases, 193 (90%) had TTE and 130 (60%) had TEE. In 119 cases with both tests, IE was diagnosed in 29 (24%), for whom endocardial involvement was evident in 25 (86%) by TEE, vs only 6 (21%) by TTE (P < .001). Transesophageal echocardiography was more sensitive than TTE regardless of risk factors. Even among the 66 cases with adequate or better quality TTE images, sensitivity was only 4 of 17 (24%) for TTE, vs 16 of  17 (94%) for TEE (P < .001). Among 130 patients with TEE, the TEE results, alone or with TTE results, influenced treatment duration in 56 (43%) cases and led to valve surgery in at least 4 (6%). It is notable that, despite vigorous efforts to obtain both tests routinely, TEE was not done in 86 cases (40%) for various reasons, including pathophysiological contraindications (14%), patient refusal or other patient-related factors (16%), and provider declination or system issues (10%).

Conclusions.

Patients with SAB should undergo TEE when possible to detect evidence for IE, especially if the results might affect management.

FULL TEXT

https://academic.oup.com/ofid/article/4/2/ofx035/3044172

PDF (CLIC en PDF)

July 15, 2018 at 3:52 pm

Association Between CMV Reactivation and Clinical Outcomes in Immunocompetent Critically Ill Patients – Systematic Review and Meta-Analysis July 2018

Background

The aim of our systematic review was to investigate the association between cytomegalovirus (CMV) reactivation and outcomes in immunocompetent critically ill patients.

Methods

We searched electronic databases and gray literature for original studies and abstracts published between 1990 and October 2016. The review was limited to studies including critically ill immunocompetent patients. Cytomegalovirus reactivation was defined as positive polymerase chain reaction, pp65 antigenemia, or viral culture from blood or bronchoalveolar lavage. Selected patient-centered outcomes included mortality, duration of mechanical ventilation, need for renal replacement therapy (RRT), and nosocomial infections. Health resource utilization outcomes included intensive care unit and hospital lengths of stay.

Results

Twenty-two studies were included. In our primary analysis, CMV reactivation was associated with increased ICU mortality (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.87–3.47), overall mortality (OR, 2.02; 95% CI, 1.60–2.56), duration of mechanical ventilation (mean difference 6.60 days; 95% CI, 3.09–10.12), nosocomial infections (OR, 3.20; 95% CI, 2.05–4.98), need for RRT (OR, 2.37; 95% CI, 1.31–4.31), and ICU length of stay (mean difference 8.18 days; 95% CI, 6.14–10.22). In addition, numerous sensitivity analyses were performed.

Conclusions

In this meta-analysis, CMV reactivation was associated with worse clinical outcomes and greater health resource utilization in critically ill patients. However, it remains unclear whether CMV reactivation plays a causal role or if it is a surrogate for more severe illness.

https://academic.oup.com/ofid/article/4/2/ofx029/2991368

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July 15, 2018 at 3:48 pm

Bloodstream infections in cancer patients. Risk factors associated with mortality

International Journal of Infectious Diseases June 2018 V.71 P.59-64

Beda Islas-Muñoz, Patricia Volkow-Fernández, Cynthia Ibanes-Gutiérrez, Alberto Villamar-Ramírez, Diana Vilar-Compte, Patricia Cornejo-Juárez

Highlights

  • Bloodstream infections (BSI) cause severe complications in cancer patients.
  • Secondary BSI and central-related BSI were the most common in solid tumors.
  • Primary BSI and mucosal barrier injury BSI were described in hematological patients.
  • Mortality at 30-days was increased with multidrug resistant Gram-negative bacteria.
  • Inappropriate antimicrobial treatment in the first 24 h was related with mortality.

Objective

The aim of this study was to evaluate the clinical characteristics and risk factors associated with mortality in cancer patients with bloodstream infections (BSI), analyzing multidrug resistant bacteria (MDR).

Methods

We conducted a prospective observational study at a cancer referral center from August 2016 to July 2017, which included all BSI.

Results

4220 patients were tested with blood cultures; 496 were included. Mean age was 48 years. In 299 patients with solid tumors, secondary BSI and Central Line-Associated BSI (CLABSI) were the most common (55.9% and 31.8%, respectively). In 197 hematologic patients, primary and mucosal barrier injury (MBI) BSI were the main type (38.6%). Gram-negative were the most frequent bacteria (72.8%), with Escherichia coli occupying the first place (n = 210, 42.3%), 48% were Extended-Spectrum Beta-Lactamase (ESBL) producers, and 1.8% were resistant to carbapenems. Mortality at day 30, was 22%, but reached 70% when patients did not receive an appropriate antimicrobial treatment. Multivariate analysis showed that progression or relapse of the oncologic disease, inappropriate antimicrobial treatment, and having resistant bacteria were independently associated with 30-day mortality.

Conclusions

Emergence of MDR bacteria is an important healthcare problem worldwide. Patients with BSI, particularly those patients with MDR bacteria have a higher mortality risk.

PDF

https://www.ijidonline.com/article/S1201-9712(18)30081-X/pdf

July 14, 2018 at 7:25 pm

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