Posts filed under ‘Infecciones nosocomiales’

Outbreak of a Multiresistant Klebsiella pneumoniae Strain in an Intensive Care Unit: Antibiotic Use as Risk Factor for Colonization and Infection

Clinical Infectious Diseases January 2000 V.30 N.1 P. 55-60

Angel Asensio, Antonio Oliver, Paulino González-Diego, Fernando Baquero, Jose Claudio Pérez-Díaz, Purificación Ros, Javier Cobo, Margarita Palacios, Dolores Lasheras, and Rafael Cantón

1Servicio de Medicina Preventiva, Hospital Ramón y Cajal, Universidad de Alcalá, Madrid, Spain

2Servicio de Microbiología, Hospital Ramón y Cajal, Universidad de Alcalá, Madrid, Spain

3Unidad de Enfermedades Infecciosas, Hospital Ramón y Cajal, Universidad de Alcalá, Madrid, Spain

4Unidad Pediátrica de Cuidados Intensivos, Hospital Ramón y Cajal, Universidad de Alcalá, Madrid, Spain

An observational study was undertaken to describe a nosocomial outbreak caused by multiresistant Klebsiella pneumoniae (MRKP).

Ten patients in the pediatric intensive care unit (ICU) at a hospital in Madrid were colonized by or infected with MRKP from October 1997 to April 1998.

Thirty-two patients with MRKP-negative surveillance cultures who were admitted to the ICU during the outbreak period were selected as control patients. Random amplified polymorphic DNA analysis of MRKP isolates revealed patterns that were indistinguishable from each other.

After identification of colonized patients by surveillance cultures and implementation of standard and contact precautions, the outbreak was controlled.

An age <12 weeks (odds ratio [OR], 13.1) and previous treatment with third-generation cephalosporins and aminoglycosides (OR, 31.2) were independently associated with MRKP colonization and/or infection.

Individual exposure to antibiotics, irrespective of other clinical determinants, is a risk factor for MRKP acquisition.

Screening high-risk patients during outbreaks and reducing the use of third-generation cephalosporins and amino-glycosides contribute to the control of these epidemics.



December 2, 2017 at 7:58 am

International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT).

Eur Respir J. September 10, 2017 V.50 N.3.

Torres A1,2, Niederman MS3,2, Chastre J4, Ewig S5, Fernandez-Vandellos P6, Hanberger H7, Kollef M8, Li Bassi G9, Luna CM10, Martin-Loeches I11, Paiva JA12, Read RC13, Rigau D14, Timsit JF15, Welte T16, Wunderink R17.

Author information

1 Dept of Pulmonology, Hospital Clínic de Barcelona, Universitat de Barcelona and IDIBAPS, CIBERES, Barcelona, Spain

2 These two authors contributed equally to this work.

3 Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA.

4 Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.

5 CAPNETZ Stiftung and Thorax Centre in the Ruhr Area, Dept of Respiratory Medicine and Infectious Diseases, Evangelic Hospital in Herne and Augusta Hospital in Bochum, Bochum, Germany.

6 IDIBAPS, CIBERES, Barcelona, Spain.

7 Dept of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.

8 Pulmonary and Critical Care Division, Washington University School of Medicine, St Louis, MO, USA.

9 Dept of Pulmonology, Hospital Clínic de Barcelona, Universitat de Barcelona and IDIBAPS, CIBERES, Barcelona, Spain.

10 Hospital de Clínicas “José de San Martin”, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina.

11 Dept of Clinical Medicine, Wellcome Trust – HRB Clinical Research Facility, St James’s Hospital, Trinity College, Dublin, Ireland and CIBERES, Barcelona, Spain.

12 Emergency and Intensive Care Dept, Centro Hospitalar São João EPE and Dept of Medicine, University of Porto Medical School, Porto, Portugal.

13 Academic Unit of Clinical Experimental Sciences and NIHR Southampton Biomedical Research Unit, Faculty of Medicine, and Institute for Life Sciences, University of Southampton, Southampton, UK.

14 Iberoamerican Cochrane Centre, Barcelona, Spain.

15 IAME, INSERM UMR 1137, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University and Bichat Hospital, Paris, France.

16 Dept of Respiratory Medicine, Medizinische Hoschschule Hannover, Hannover and German Centre of Lung Research (DZL), Germany.

17 Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.


The most recent European guidelines and task force reports on hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) were published almost 10 years ago.

Since then, further randomised clinical trials of HAP and VAP have been conducted and new information has become available. Studies of epidemiology, diagnosis, empiric treatment, response to treatment, new antibiotics or new forms of antibiotic administration and disease prevention have changed old paradigms.

In addition, important differences between approaches in Europe and the USA have become apparent.

The European Respiratory Society launched a project to develop new international guidelines for HAP and VAP.

Other European societies, including the European Society of Intensive Care Medicine and the European Society of Clinical Microbiology and Infectious Diseases, were invited to participate and appointed their representatives.

The Latin American Thoracic Association was also invited.A total of 15 experts and two methodologists made up the panel. Three experts from the USA were also invited (Michael S. Niederman, Marin Kollef and Richard Wunderink).

Applying the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology, the panel selected seven PICO (population-intervention-comparison-outcome) questions that generated a series of recommendations for HAP/VAP diagnosis, treatment and prevention.



November 22, 2017 at 12:00 pm

Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in a low-endemicity, non-outbreak hospital setting.

Aliment Pharmacol Ther. 2009 Mar 15;29(6):626-34.

Dalton BR1, Lye-Maccannell T, Henderson EA, Maccannell DR, Louie TJ.

Author information

1Department of Pharmacy Services, Calgary Health Region, Calgary, AB, Canada.



Proton pump inhibitors (PPI) have been linked to higher risk of Clostridium difficile infection (CDI). The relevance of this association in hospitals with low disease activity, where an outbreak strain is nondominant, has been assessed in relatively few studies.


To assess the association of PPI and CDI in a setting of low disease activity.


A retrospective cohort study was conducted at two hospitals. Patients admitted for > or = 7 days receiving antibiotics were included. Demographics, exposure to PPI, antibiotics and other drugs in relation to diagnosis of CDI were assessed by univariate and multivariate analyses.


Of 14 719 patients, 149 (1%) first episode CDI were documented; PPI co-exposure increased CDI [1.44 cases/100 patients vs. 0.74 cases/100 non-exposed (OR: 1.96, 95% CI: 1.42-2.72)]. By logistic regression, PPI days (adjusted OR: 1.01 per day, 95% CI: 1.00-1.02), histamine-2 blockers, antidepressants, antibiotic days, exposure to medications, age, admission service and length of admission were significant predictors.


A statistically significant increase in CDI was observed in antibiotic recipients who received PPI, but the absolute risk increase is modest. In settings of with low rates of CDI, the benefit of PPI therapy outweighs the risk of developing CDI. These data support programmes to decrease inappropriate use of PPI in hospitalized patients.


November 14, 2017 at 9:14 am

Control of an outbreak of infection with the hypervirulent Clostridium difficile BI strain in a university hospital using a comprehensive “bundle” approach.

Clin Infect Dis. 2007 Nov 15;45(10):1266-73.

Muto CA1, Blank MK, Marsh JW, Vergis EN, O’Leary MM, Shutt KA, Pasculle AW, Pokrywka M, Garcia JG, Posey K, Roberts TL, Potoski BA, Blank GE, Simmons RL, Veldkamp P, Harrison LH, Paterson DL.

Author information

1Division of Hospital Epidemiology and Infection Control, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.



In June 2000, the hospital-acquired Clostridium difficile (CD) infection rate in our hospital (University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, PA) increased to 10.4 infections per 1000 hospital discharges (HDs); the annual rate increased from 2.7 infections per 1000 HDs to 7.2 infections per 1000 HDs and was accompanied by an increase in the frequency of severe outcomes. Forty-seven (51%) of 92 HA CD isolates in 2001 were identified as the “epidemic BI strain.” A comprehensive CD infection control “bundle” was implemented to control the outbreak of CD infection.


The CD infection control bundle consisted of education, increased and early case finding, expanded infection-control measures, development of a CD infection management team, and antimicrobial management. Process measures, antimicrobial usage, and hospital-acquired CD infection rates were analyzed, and CD isolates were typed.


The rates of compliance with hand hygiene and isolation were 75% and 68%, respectively. The CD management team evaluated a mean of 31 patients per month (11% were evaluated for moderate or severe disease). Use of antimicrobial therapy associated with increased CD infection risk decreased by 41% during the period 2003-2005 (P<.001). The aggregate rate of CD infection during the period 2001-2006 decreased to 4.8 infections per 1000 HDs (odds ratio, 2.2; 95% confidence interval, 1.4-3.1; P<.001) and by 2006, was 3.0 infections per 1000 HDs, a rate reduction of 71% (odds ratio, 3.5; 95% confidence interval, 2.3-5.4; P<.001). During the period 2000-2001, the proportion of severe CD cases peaked at 9.4% (37 of 393 CD infections were severe); the rate decreased to 3.1% in 2002 and further decreased to 1.0% in 2006–a 78% overall reduction (odds ratio, 20.3; 95% confidence interval, 2.8-148.2; P<.001). In 2005, 13% of CD isolates were type BI (20% were hospital acquired), which represented a significant reduction from 2001 (P<.001).


The outbreak of CD infection with the BI strain in our hospital was controlled after implementing a CD infection control “bundle.” Early identification, coupled with appropriate control measures, reduces the rate of CD infection and the frequency of adverse events.


November 14, 2017 at 9:12 am

Long term effect of infection control practices and associated factors during a major Clostridium difficile outbreak in Costa Rica.

J Infect Dev Ctries. 2013 Dec 15;7(12):914-21.

Wong-McClure RA1, Ramírez-Salas E, Mora-Brenes N, Aguero-Sandí L, Morera-Sigler M, Badilla-Vargas X, Hernández-de Merzerville M, O’Shea M, Bryce E.

Author information

1Epidemiology Office and Surveillance, Caja Costarricense de Seguro Social, Genaro Valverde Building, Second Avenue, San José, Costa Rica.



The C. difficile BI/NAP 1 hyper virulent strain has been responsible for the nosocomial outbreaks in several countries. The present study describes the infection control strategies utilized to achieve outbreak control as well as the factors associated with a C. difficile BI/NAP 1 hyper virulent strain outbreak in Costa Rica.


A descriptive analysis of the C. difficile outbreak was completed for the period of January 2007 to December 2010 in one affected hospital. An unmatched case-control study was subsequently performed to evaluate the association of exposure factors with C. difficile infection.


The pattern of the outbreak was characterized by a sharp increase in the incidence rate during the initial weeks of the outbreak, which was followed by a reduction in the incidence curve as several infection control measures were implemented. The C. difficile BI/NAP1 infection was associated with the prescription of antibiotics, in particular levofloxacin (OR: 9.3; 95%CI: 2.1-40.2), meropenem (OR: 4.9, 95%CI: 1.0-22.9), cefotaxime (OR: 4.3, 95%CI: 2.4-7.7), as well as a medical history of diabetes mellitus (OR: 2.9, 95%CI: 1.5-5.8).


The infection control strategies implemented proved to be effective in achieving outbreak control and in maintaining the baseline C. difficile incidence rate following it. The reported C. difficile outbreak was associated with the prescription of broad-spectrum antibiotics and a medical history of diabetes.


November 14, 2017 at 9:11 am

Clostridium difficile infection in the community: are proton pump inhibitors to blame?

World J Gastroenterol. 2013 Oct 28;19(40):6710-3.

Freedberg DE1, Abrams JA.

Author information

1Daniel E Freedberg, Julian A Abrams, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY 10032, United States.


Once a nosocomial disease, Clostridium difficile infection (CDI) now appears frequently in the community in the absence of exposure to antibiotics.

Prior studies have shown that patients with community-acquired CDI are younger, more likely to be female, and have fewer comorbidities compared to patients with hospital-associated CDI.

Because most studies of CDI are hospital-based, comparatively little is known about community-acquired CDI.

The recent study by Chitnis has received widespread attention because it used active surveillance to capture all cases of community-acquired CDI within a large population and assessed key risk factors.

The authors found that low-level healthcare exposure and proton pump inhibitor use were common among those with non-antibiotics associated, community-acquired CDI.

In this commentary, we discuss the changing epidemiology of community-acquired CDI and the evidence basis for the controversial association between proton pump inhibitors and community-acquired CDI.


November 14, 2017 at 9:10 am

Prevalence of Clostridium difficile colonization among healthcare workers.

BMC Infect Dis. 2013 Oct 4;13:459.

Friedman ND1, Pollard J, Stupart D, Knight DR, Khajehnoori M, Davey EK, Parry L, Riley TV.

Author information

1Department of Medicine and Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.



Clostridium difficile infection (CDI) has increased to epidemic proportions in recent years. The carriage of C. difficile among healthy adults and hospital inpatients has been established. We sought to determine whether C. difficile colonization exists among healthcare workers (HCWs) in our setting.


A point prevalence study of stool colonization with C. difficile among doctors, nurses and allied health staff at a large regional teaching hospital in Geelong, Victoria. All participants completed a short questionnaire and all stool specimens were tested by Techlab® C.diff Quik Check enzyme immunoassay followed by enrichment culture.


Among 128 healthcare workers, 77% were female, of mean age 43 years, and the majority were nursing staff (73%). Nineteen HCWs (15%) reported diarrhoea, and 12 (9%) had taken antibiotics in the previous six weeks. Over 40% of participants reported having contact with a patient with known or suspected CDI in the 6 weeks before the stool was collected. C. difficile was not isolated from the stool of any participants.


Although HCWs are at risk of asymptomatic carriage and could act as a reservoir for transmission in the hospital environment, with the use of a screening test and culture we were unable to identify C. difficile in the stool of our participants in a non-outbreak setting. This may reflect potential colonization resistance of the gut microbiota, or the success of infection prevention strategies at our institution.


November 14, 2017 at 9:08 am

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