Posts filed under ‘Infecciones intraabdominales’

A Laboratory Medicine Best Practices Systematic Review and Meta-analysis of Nucleic Acid Amplification Tests (NAATs) and Algorithms Including NAATs for the Diagnosis of Clostridioides (Clostridium) difficile in Adults

Clinical Microbiololy Reviwes July 2019 V.32 N.3

The evidence base for the optimal laboratory diagnosis of Clostridioides (Clostridium) difficile in adults is currently unresolved due to the uncertain performance characteristics and various combinations of tests. This systematic review evaluates the diagnostic accuracy of laboratory testing algorithms that include nucleic acid amplification tests (NAATs) to detect the presence of C. difficile. The systematic review and meta-analysis included eligible studies (those that had PICO [population, intervention, comparison, outcome] elements) that assessed the diagnostic accuracy of NAAT alone or following glutamate dehydrogenase (GDH) enzyme immunoassays (EIAs) or GDH EIAs plus C. difficile toxin EIAs (toxin). The diagnostic yield of NAAT for repeat testing after an initial negative result was also assessed. Two hundred thirty-eight studies met inclusion criteria. Seventy-two of these studies had sufficient data for meta-analysis. The strength of evidence ranged from high to insufficient. The uses of NAAT only, GDH-positive EIA followed by NAAT, and GDH-positive/toxin-negative EIA followed by NAAT are all recommended as American Society for Microbiology (ASM) best practices for the detection of the C. difficile toxin gene or organism. Meta-analysis of published evidence supports the use of testing algorithms that use NAAT alone or in combination with GDH or GDH plus toxin EIA to detect the presence of C. difficile in adults. There is insufficient evidence to recommend against repeat testing of the sample using NAAT after an initial negative result due to a lack of evidence of harm (i.e., financial, length of stay, or delay of treatment) as specified by the Laboratory Medicine Best Practices (LMBP) systematic review method in making such an assessment. Findings from this systematic review provide clarity to diagnostic testing strategies and highlight gaps, such as low numbers of GDH/toxin/PCR studies, in existing evidence on diagnostic performance, which can be used to guide future clinical research studies.

FULL TEXT

https://cmr.asm.org/content/32/3/e00032-18.abstract?etoc

PDF

https://cmr.asm.org/content/cmr/32/3/e00032-18.full.pdf

June 19, 2019 at 2:57 pm

Antibiotics for operative vaginal delivery –  practice-changing data

LANCET June 15, 2019 V.393 N.10189 P.2361-2362

COMMENT

Antibiotics for operative vaginal delivery –  practice-changing data

The large randomised controlled trial on the effect of antibiotics to prevent infection after operative vaginal delivery by Marian Knight and colleagues1 in The Lancet is practice changing. Operative vaginal deliveries include either vacuum or forceps, and are used in about 2–15% of births.2 Even if one conservatively estimates 2% of babies are born by operative vaginal delivery globally, about 2 700 000 of the world’s 135 million annual births are operative vaginal deliveries. Up to 16% of these births can be associated with infection without antibiotics prophylaxis,3 representing about 432 000 annual infections associated with operative vaginal delivery worldwide……

FULL TEXT

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30845-1/fulltext?dgcid=raven_jbs_etoc_email

PDF

https://www.thelancet.com/action/showPdf?pii=S0140-6736%2819%2930845-1

 

LANCET June 15, 2019 V.393 N.10189 P.2395-2403

ARTICLES

Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial

Background

Risk factors for maternal infection are clearly recognised, including caesarean section and operative vaginal birth. Antibiotic prophylaxis at caesarean section is widely recommended because there is clear systematic review evidence that it reduces incidence of maternal infection. Current WHO guidelines do not recommend routine antibiotic prophylaxis for women undergoing operative vaginal birth because of insufficient evidence of effectiveness. We aimed to investigate whether antibiotic prophylaxis prevented maternal infection after operative vaginal birth.

Methods

In a blinded, randomised controlled trial done at 27 UK obstetric units, women (aged ≥16 years) were allocated to receive a single dose of intravenous amoxicillin and clavulanic acid or placebo (saline) following operative vaginal birth at 36 weeks gestation or later. The primary outcome was confirmed or suspected maternal infection within 6 weeks of delivery defined by a new prescription of antibiotics for specific indications, confirmed systemic infection on culture, or endometritis. We did an intention-to-treat analysis. This trial is registered with ISRCTN, number 11166984, and is closed to accrual.

Findings

Between March 13, 2016, and June 13, 2018, 3427 women were randomly assigned to treatment: 1719 to amoxicillin and clavulanic acid, and 1708 to placebo. Seven women withdrew, leaving 1715 in the amoxicillin and clavulanic acid group and 1705 in the placebo groups. Primary outcome data were missing for 195 (6%) women. Significantly fewer women allocated to amoxicillin and clavulanic acid had a confirmed or suspected infection (180 [11%] of 1619) than women allocated to placebo (306 [19%] of 1606; risk ratio 0·58, 95% CI 0·49–0·69; p<0·0001). One woman in the placebo group reported a skin rash and two women in the amoxicillin and clavulanic acid reported other allergic reactions, one of which was reported as a serious adverse event. Two other serious adverse events were reported, neither was considered causally related to the treatment.

Interpretation

This trial shows benefit of a single dose of prophylactic antibiotic after operative vaginal birth and guidance from WHO and other national organisations should be changed to reflect this.

Funding

NIHR Health Technology Assessment programme.

FULL TEXT

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30773-1/fulltext?dgcid=raven_jbs_etoc_email

PDF

https://www.thelancet.com/action/showPdf?pii=S0140-6736%2819%2930773-1

June 14, 2019 at 3:54 pm

Outcomes of Community and Healthcare-onset Clostridium difficile Infections

Clinical Infectious Diseases April 15, 2019 V.68 N.8 P.1343-1350  

EDITOR’S CHOICE

Between 2011 and 2014, of the Clostridium difficile infections (CDI) cases in the Veterans Health Administration system, 44% were hospital-onset and 42% were community-onset (CO). CDI prevention efforts should include interventions to reduce CO CDIs.

Background

Community-onset Clostridium difficile infections (CDI) are increasingly common, but there is little data on outcomes. The purpose of this study is to describe the epidemiology and outcomes of CDI in the Veterans Health Administration (VHA) system and compare these variables between hospital-onset (HCF) and community-onset (CO) cases.

Methods

We conducted a retrospective cohort study that included all patients with a positive test for C. difficile (toxin or toxin genes) within the VHA Corporate Data Warehouse between 2011 and 2014.

Results

We identified 19270 episodes of CDI, involving 15972 unique patients; 95% were male, 44% of the cases were HCF, and 42% were CO. Regarding severity, 31% percent of cases were non-severe, 40% were severe, and 21% were fulminant. Exposure to proton pump inhibitors was found in 53% of cases (47% in CO, 62% in HCF). Overall, 40% of patients received antibiotics in the 90 days before CDI (44% in HCF, 36% in CO). Recurrence was 18.2%, and 30-day all-cause mortality was 9.2%. Risk factors for a fulminant case were exposure to clindamycin (odds ratio [OR]: 1.23, P = .01) or proton pump inhibitors (OR: 1.20, P < .001)  in the 90 days prior to diagnosis.

Conclusions

CO accounts for a significant proportion of CDI in the VHA system. CO patients are younger and their cases are less severe, but recurrence is more common than in HCF CDI. Therefore CO CDI may account for a considerable reservoir of CDI cases, and prevention efforts should include interventions to reduce CO CDI.

FULL TEXT

https://academic.oup.com/cid/article/68/8/1343/5078569

PDF (CLIC en PDF)

May 4, 2019 at 12:19 pm

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

World J Emerg Surg. 2019 Mar 4;14:10.

Pisano M, Ceresoli M, Cimbanassi S, Gurusamy K, Coccolini F, Borzellino G, et al

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

FULL TEXT

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399945/

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399945/pdf/13017_2019_Article_224.pdf

April 3, 2019 at 8:37 am

Procalcitonin in patients with fever: one approach does not fit all

Clinical Microbiology and Infection December 2018 V.24 N.12 P.1229–1230

Schuetz, A.R. Falsey

The value of antibiotics for human health is boundless, but the recent emergence of antimicrobial resistance has become a critical threat to this treasure [1].

Reducing selection pressure on drug-resistant pathogens by a more rational use of antimicrobials is now an international priority.

Patients presenting to the emergency department with fever may present opportunities to improve antimicrobial usage by the addition of novel host-directed markers, such as procalcitonin (PCT), to clinical judgment and pathogen-directed tests [2].

Although previous trials found PCT to decrease antibiotic usage and improve clinical outcomes in specific indications such as lower respiratory tract infection [3] and sepsis [4], the value of PCT in patients with fever without specified clinical syndrome has been understudied. . . .

FULL TEXT

https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(18)30540-8/fulltext

PDF

https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(18)30540-8/pdf

January 11, 2019 at 8:12 pm

Shorter duration of antibiotic treatment for acute bacteraemic cholangitis with successful biliary drainage: a retrospective cohort study

Clinical Microbiology and Infection November 2018 V.24 N.11 P.1184–1189

Doi, T. Morimoto, K. Iwata

Objectives

To assess the effectiveness of short duration antimicrobial therapy for acute cholangitis with bacteraemia.

Methods

We conducted a retrospective cohort study of patients with acute bacteraemic cholangitis with successful biliary duct drainage at a single centre in Japan. We compared short-course antimicrobial therapy (SCT, ≤7 days) and long-course therapy (LCT, ≥8 days), with a primary outcome of 30-day mortality. We constructed logistic regression models for mortality and a composite outcome, including mortality, recurrence, recrudescence, new bacteraemia, liver abscess or other complications related to cholangitis. We also developed a propensity score for SCT with inverse probability weighting for both the primary outcome and the composite outcome.

Results

We identified 263 patients in our cohort; 86 (32.7%) patients received SCT and the remaining 177 (67.3%) received LCT. The median durations of SCT and LCT were 6 days (range 2–7 days) and 12 days (range 8–46 days), respectively. The 30-day mortalities of SCT and LCT were 4.7% (4/85) and 5.7% (10/176), respectively (p 1.00). Logistic regression analysis showed that the odds ratio of SCT for 30-day mortality and the composite outcome were 1.07 (95% CI 0.25–4.52, p 0.93) and 1.08 (95% CI 0.48–2.45, p 0.85), respectively. Propensity score analyses for both 30-day mortality and the composite outcome did not demonstrate a difference between SCT and LCT (p 0.65 and p 0.95, respectively).

Conclusions

SCT with a median duration of 6 days did not have worse outcomes than LCT with a median duration of 12 days. Shortening the duration of antimicrobial therapy may be a reasonable option when treating acute bacteraemic cholangitis following successful biliary drainage.

FULL TEXT

https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(18)30139-3/fulltext

PDF

https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(18)30139-3/pdf

January 11, 2019 at 8:11 pm

The Most Effective Treatments for Clostridium difficile Diarrhea: An Evidence-Based Review

Infectious Diseases in Clinical Practice May 2011 V.19 N.3 P.171-181

Griffin, Allen Thomas; Arnold, Forest Wayne

Clostridium difficile is more common, more virulent, and more difficult to treat than in past decades.

Oral vancomycin and metronidazole have been the subject of the most rigorous study in this disease. Although these antibiotics have largely been viewed as equivalent, studies support vancomycin for severe disease, whereas metronidazole is noninferior in milder disease.

Both antibiotics are superior to the toxin-binding agent tolevamer. No evidence supports probiotics for initial disease, but there may be utility in relapsing disease. There is an exiguous evidence base regarding antibiotic treatment of relapsing disease, but tapered and pulsed regimens of vancomycin remain possible options.

Preliminary evidence supports the use of monoclonal antibodies against C. difficile toxins A and B for relapsing episodes.

The studies concerning refractory disease are limited to a case series design, whereas it remains unclear how effective probiotics are in the prevention of C. difficile infection.

FULL TEXT

https://journals.lww.com/infectdis/Fulltext/2011/05000/The_Most_Effective_Treatments_for_Clostridium.7.aspx

PDF (CLIC en PDF)

December 7, 2018 at 9:26 am

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