[Show abstract][Hide abstract]ABSTRACT: Background. There is an urgent need for alternative rescue therapies in invasive infections caused by methicillin-resistant Staphylococcus aureus (MRSA). We assessed the clinical efficacy and safety of the combination of fosfomycin and imipenem as rescue therapy for
MRSA infective endocarditis and complicated bacteremia.
Methods. The trial was conducted between 2001 and 2010 in 3 Spanish hospitals. Adult patients with complicated MRSA bacteremia or
endocarditis requiring rescue therapy were eligible for the study. Treatment with fosfomycin (2 g/6 hours IV) plus imipenem
(1 g/6 hours IV) was started and monitored. The primary efficacy endpoints were percentage of sterile blood cultures at 72
hours and clinical success rate assessed at the test-of-cure visit (45 days after the end of therapy).
Results. The combination was administered in 12 patients with endocarditis, 2 with vascular graft infection, and 2 with complicated
bacteremia. Therapy had previously failed with vancomycin in 9 patients, daptomycin in 2, and sequential antibiotics in 5.
Blood cultures were negative 72 hours after the first dose of the combination in all cases. The success rate was 69%, and
only 1 of 5 deaths was related to the MRSA infection. Although the combination was safe in most patients (94%), a patient
with liver cirrhosis died of multiorgan failure secondary to sodium overload. There were no episodes of breakthrough bacteremia
Conclusions. Fosfomycin plus imipenem was an effective and safe combination when used as rescue therapy for complicated MRSA bloodstream
infections and deserves further clinical evaluation as initial therapy in these infections.
[Show abstract][Hide abstract]ABSTRACT: The present article is an update of the literature on endocarditis. A multidisciplinary group of Spanish physicians with an interest in cardiac infections selected the most important papers produced lately in the field. Two of the members of the group discussed the content of each of the selected papers, with a critical review by others members of the panel. After a review of the state of the art papers from the fields of epidemiology, new causative microorganisms (bacterial and fungal), clinical findings including those in special patients, laboratory diagnosis, prognostic factors, nosocomial endocarditis, prophylaxis, new drugs and guidelines for antibiotic treatment were discussed by the group.
No preview · Article · Mar 2011 · Enfermedades Infecciosas y Microbiología Clínica
[Show abstract][Hide abstract]ABSTRACT: Introduction: Catheter-related bloodstream infection (CR-BSI) is a cause of morbidity and mortality in intensive care units, and the optimal approach for preventing these infections is not well defined. Comparison of CR-BSI rates with those provided by programs such as the National Nosocomial Infection Surveillance System (NNISS) from the USA and the Spanish National Nosocomial Infection Surveillance Study (ENVIN), enable determination of the need to implement control measures. In 2000, we found that the CR-BSI rates in UCIs of our hospital were much higher than the data reported by ENVIN. Objective: To assess the impact of implementing a protocol for proper use of intravascular catheters on CR-BSI rates in the intensive care unit (ICU) of a tertiary hospital. Methods: Prospective study of patients admitted to the ICUs of a tertiary hospital in the months of May and June, from 2000 to 2004. In 2001, a CR-BSI prevention program including aspects related to catheter insertion and maintenance in ICU patients was implemented. We calculated infection rates per 1000 days of catheter use in all the 2-month periods studied, and compared the 2000 and 2004 results by analysis of the odds ratios and confidence intervals.
[Show abstract][Hide abstract]ABSTRACT: Catheter-related bloodstream infection (CR-BSI) is a cause of morbidity and mortality in intensive care units, and the optimal approach for preventing these infections is not well defined. Comparison of CR-BSI rates with those provided by programs such as the National Nosocomial Infection Surveillance System (NNISS) from the USA and the Spanish National Nosocomial Infection Surveillance Study (ENVIN), enable determination of the need to implement control measures. In 2000, we found that the CR-BSI rates in UCIs of our hospital were much higher than the data reported by ENVIN.
To assess the impact of implementing a protocol for proper use of intravascular catheters on CR-BSI rates in the intensive care unit (ICU) of a tertiary hospital.
Prospective study of patients admitted to the ICUs of a tertiary hospital in the months of May and June, from 2000 to 2004. In 2001, a CR-BSI prevention program including aspects related to catheter insertion and maintenance in ICU patients was implemented. We calculated infection rates per 1000 days of catheter use in all the 2-month periods studied, and compared the 2000 and 2004 results by analysis of the odds ratios and confidence intervals.
A total of 923 patients were included. Mean age was 58.7 years (SD: 15.4), mean ICU stay was 11.6 days (SD: 11.4), mean SAPSII was 28.2 (SD: 15.9), and mortality was 20.5%. There was a significant reduction in CR-BSI rates from 13.3 episodes per 1000 days of catheter use in the first period to 3.21 in the last period (OR=3.53, 95% CI: 2.36-5.31).
Application of a prevention program for CR-BSI and a system for monitoring BSI rates led to a significant, sustained reduction in these infections.
Full-text · Article · Aug 2009 · Enfermedades Infecciosas y Microbiología Clínica
[Show abstract][Hide abstract]ABSTRACT: To describe the incidence and clinical characteristics of imipenem-resistant (IR) Pseudomonas aeruginosa bacteraemia.
We performed a retrospective study including all episodes of IR P. aeruginosa bacteraemia seen from January 2003 to December 2005 in a tertiary teaching hospital.
There were 108 episodes of IR P. aeruginosa bacteraemia, which represented an incidence of 0.14 episodes per 1000 patient-days in 2003 and 0.11 episodes per 1000 patient-days in 2005. 83 of the episodes (77%) were nosocomially acquired. Most of patients had at least one underlying disease and had previously received antimicrobial treatment. The most frequent source was the urinary tract (31%), followed by unknown origin (22%). A total of 23 (21%) episodes were polymicrobial and 51 (47%) were caused by multidrug-resistant strains. The independent risk factors for mortality from IR P. aeruginosa bloodstream infection were a high-risk source of the bacteraemia (OR: 4.6; 95% CI 1.7-12.4; p=0.01), and presentation with severe sepsis (OR: 2.8; 95% CI 1-7.8; p=0.05).
Our study shows that the rates of IR P. aeruginosa bacteraemia remained stable throughout the study period. The source of bacteraemia and the clinical presentation with severe sepsis were the main determinants of the prognosis.
No preview · Article · May 2009 · The Journal of infection
[Show abstract][Hide abstract]ABSTRACT: Bacteremia and endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) are prevalent and clinically important. The rise in MRSA bacteremia and endocarditis is related with the increasing use of venous catheters and other vascular procedures. Glycopeptides have been the reference drugs for treating these infections. Unfortunately their activity is not completely satisfactory, particularly against MRSA strains with MICs > 1 microg/mL. The development of new antibiotics, such as linezolid and daptomycin, and the promise of future compounds (dalvabancin, ceftobiprole and telavancin) may change the expectatives in this field.The principal aim of this consensus document was to formulate several recommendations to improve the outcome of MRSA bacteremia and endocarditis, based on the latest reported scientific evidence. This document specifically analyzes the approach for three clinical situations: venous catheter-related bacteremia, persistent bacteremia, and infective endocarditis due to MRSA.
No preview · Article · Mar 2009 · Enfermedades Infecciosas y Microbiología Clínica
[Show abstract][Hide abstract]ABSTRACT: El presente artículo recoge una actualización bibliográfica de patógenos bacterianos. Dado el interés científico y la importancia que tienen para la salud pública las infecciones producidas por patógenos bacterianos con nuevos mecanismos de virulencia y/o nuevos mecanismos de resistencia a los antimicrobianos, un grupo multidisciplinario de microbiólogos y clínicos españoles, con experiencia en enfermedades infecciosas, organizó una reunión en la que se revisaron los artículos más importantes en este campo, publicados en 2006.
El contenido de cada uno de los artículos seleccionados fue expuesto y discutido por uno de los miembros del grupo. Este artículo revisa algunas de las enfermedades infecciosas bacterianas que suponen hoy en día algunos de los principales retos para la salud pública e incluye las infecciones producidas por Staphylococcus aureus resistente a meticilina de adquisición comunitaria, las producidas por variantes de colonia pequeña de S. aureus, las relacionadas con estafilococos coagulasa negativa multirresistentes, la infección neumocócica, la listeriosis humana, la infección meningocócica, la tos ferina, las infecciones por Haemophilus influenzae, la diseminación de las bacterias productoras de BLEE, y las infecciones por bacilos gramnegativos no fermentadores. Tras la revisión de la situación actual, se discuten y comentan diferentes artículos relacionados con estos aspectos.
No preview · Article · Apr 2008 · Enfermedades Infecciosas y Microbiología Clínica
[Show abstract][Hide abstract]ABSTRACT: La sepsis grave y el shock séptico son causas frecuentes de fallecimiento en las unidades de cuidados intensivos (UCI). La incidencia de sepsis se ha incrementado durante los 2 últimos decenios y se considera que lo va a seguir haciendo durante los próximos años. A pesar de que actualmente poseemos mucha más información acerca de las complejas alteraciones fisiopatológicas que tienen lugar en la sepsis grave y en el shock séptico, los pacientes con sepsis siguen presentando un elevado riesgo de muerte. Sin embargo, durante los últimos años la introducción de nuevas estrategias terapéuticas ha mejorado significativamente el pronóstico de estos pacientes. En este artículo se revisan nueve estudios de gran envergadura publicados en 2004 y 2005: en dos de ellos se abordan las tasas de incidencia, la distribución de los patógenos y las tendencias en la resistencia frente a los antibióticos en los pacientes con sepsis atendidos en la UCI; en otros dos artículos se exponen diversos aspectos seleccionados del tratamiento antibiótico, la utilidad del tratamiento de combinación en los cuadros de sepsis que presentan los pacientes inmunocompetentes y el impacto del tratamiento empírico en los cuadros de sepsis causados por Pseudomonas aeruginosa; en otras dos publicaciones se consideran la utilidad de la evaluación del riesgo en el tratamiento de la sepsis y la importancia de una evaluación clínica dinámica en los pacientes con infección y en situación clínica crítica. En los tres estudios restantes se analiza el tratamiento complementario en la sepsis grave: el efecto de un protocolo de control intensivo de la glucemia sobre la evolución de los pacientes en situación clínica crítica; la evaluación de la insuficiencia suprarrenal relativa y de la variabilidad de las concentraciones plasmáticas de cortisol durante un período de 24 horas, y el uso de drotrecogina alfa (activada) en los adultos con sepsis grave y riesgo bajo de muerte.
No preview · Article · Jan 2007 · Enfermedades Infecciosas y Microbiología Clínica
[Show abstract][Hide abstract]ABSTRACT: To investigate an increase in the number of Salmonella enteritidis isolates detected in a large hospital to ascertain whether it was due to a nosocomial source, to identify the mechanisms of transmission, and to institute effective control measures to prevent future episodes.
Observational study, survey of all microbiological samples positive for S. enteritidis detected in the hospital, outbreak investigation, and review of the literature.
A tertiary-care teaching hospital for adults in Barcelona, Spain.
During a 7-month period from May to November 1998, we identified 22 inpatients with S. enteritidis infection for whom nosocomial acquisition was strongly suspected. The attack rate was 0.138 per 1,000 patient-days. All affected patients were immunosuppressed and overall mortality was 41% (9 of 22). A sample of a meal cooked in the kitchen was culture positive for S. enteritidis. All isolates shared the same antibiotic susceptibility pattern and all except one shared the same pulsed-field gel electrophoresis (PFGE) pattern, but PFGE could not differentiate between outbreak-related and control strains. After compliance with kitchen hygiene procedures was emphasized and cleansing was intensified, no more cases were detected.
Apparently, sporadic cases of S. enteritidis may be part of an outbreak with a low attack rate. A small but persistent inoculum affecting only individuals with special predisposition for Salmonella infection might account for this. Suspicion should be raised in hospitals and institutions with a highly susceptible population.
No preview · Article · Feb 2004 · Infection Control and Hospital Epidemiology
[Show abstract][Hide abstract]ABSTRACT: Few data are available regarding pneumococcal peritonitis. We studied the clinical characteristics of intra-abdominal infections caused by Streptococcus pneumoniae and its prognosis in relation to antibiotic resistance.
We reviewed all cases of culture-proved pneumococcal peritonitis. Patients with liver cirrhosis and primary pneumococcal peritonitis were compared with patients with Escherichia coli peritonitis.
Between January 1, 1979, and December 31, 1998, we identified 45 cases of primary pneumococcal peritonitis in patients with cirrhosis and 19 cases of secondary (or tertiary) pneumococcal peritonitis. Patients with cirrhosis and primary pneumococcal peritonitis vs those with primary E coli peritonitis had more frequent community-acquired infection, 73% vs 47%; pneumonia, 36% vs 2%; and bacteremia, 76% vs 33%; and higher attributable mortality (early mortality), 27% vs 9% (P<.05 for all). Secondary (or tertiary) pneumococcal peritonitis was associated with upper or lower gastrointestinal tract diseases; in most cases, the infection appeared after surgery. A hematogenous spread of S pneumoniae from a respiratory tract infection might be the most important origin of peritonitis; also, S pneumoniae might directly reach the gastrointestinal tract favored by endoscopic procedures or hypochlorhydria. There was an increased prevalence of penicillin and cephalosporin resistance up to 30.7% and 17.0%, respectively, although it was not associated with increased mortality rates.
Primary pneumococcal peritonitis in patients with cirrhosis more often spread hematogenously from the respiratory tract and was associated with early mortality. In secondary (and tertiary) pneumococcal peritonitis, a transient gastrointestinal tract colonization and inoculation during surgery might be the most important mechanisms. Current levels of resistance were not associated with increased mortality rates.
Preview · Article · Aug 2001 · Archives of Internal Medicine
[Show abstract][Hide abstract]ABSTRACT: In a review of 94 consecutive patients with brain abscess, about 30% ruptured into the cerebral ventricels or the subarachnoid space. Patients with ruptured brain abscess were somewhat less likely to have undergone a recent craniotomy, and were more likely to have fever, headache, or meningismus.
No preview · Article · Mar 1999 · The American Journal of Medicine
[Show abstract][Hide abstract]ABSTRACT: An outbreak due to extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-KP) was detected from May 1993 to June 1995. A total of 145 patients, particularly patients in intensive care units (ICUs) (107 patients [72%]), were colonized or infected. Infection developed in 92 (63%) patients, and primary bacteremia caused by ESBL-KP was the most frequent infection (40 of 92 patients [43%]). A single clone of ESBL-KP was identified by pulsed-field gel electrophoresis analysis throughout the whole period, and no molecular epidemiological relationship could be found between the epidemic strain and non-ESBL-KP isolates. To determine risk factors for ESBL-KP infection weekly rectal swabs were obtained in three serial incidence surveys (470 patients); the probabilities of carriage of ESBL-KP in the digestive tract were 33% (October and November 1993), 40% (May and June 1994), and 0% (October and November 1995) at 10 days of ICU admission. A logistic regression model identified prior carriage of ESBL-KP in the digestive tract (odds ratio, 3.4; 95% confidence interval 1.1 to 10.4) as an independent variable associated with ESBL-KP infection. A statistically significant correlation was observed between the restricted use of oxyimino-beta-lactams (189 defined daily doses [DDD]/ 1,000 patient-days to 24 DDD/1,000 patient-days) and the trends of ESBL-KP infection (r = 0.7; P = 0.03).
Full-text · Article · Feb 1998 · Antimicrobial Agents and Chemotherapy
[Show abstract][Hide abstract]ABSTRACT: For 16 years we prospectively observed 530 adult patients with brucellosis to analyze the characteristics of and risk factors
for relapse. Clinical and laboratory findings from 86 relapsed patients were milder during the relapse episode when compared
with those for the same patients during the initial disease. Blood cultures were positive for Brucella melitensis in 65% of cases during relapse and in ∼80% of cases during the initial disease. Risk factors that were identified as being
independently associated with relapse (by logistic regression analysis) were “less-effective” antibiotic therapy (OR, 8.3;
95% CI, 4.6–15.1), positive blood cultures during initial disease (OR, 2.7; 95% CI, 1.2–6.2), ⩽10-day duration of the disease
before treatment (OR, 1.9; 95% CI, 1.1–3.6), male sex (OR, 1.8;95%CI, 1.02–3.8), and a platelet count of ⩽150 × 103mm3 (OR, 1.7; 95% CI, 1.1–2.8). These data show that relapse of brucellosis is sometimes difficult to diagnose and that it can
be an insidious disease. In addition to inappropriate antibiotic therapy, other factors, such as those indicating a more aggressive
disease and/or a deficient immunologic response, seem to play an important role in the relapse of brucellosis.
No preview · Article · Jun 1995 · Clinical Infectious Diseases
[Show abstract][Hide abstract]ABSTRACT: Although the pharmacokinetics of ceftriaxone allows its administration in a single daily dose, this practice is not standard
in the treatment of bacterial meningitis. Herein, we review our experience and that of other investigators with this mode
of therapy. We used a single daily dose of ceftriaxone (50 mg/[kg · d]; maximum, 4 g/d) for the treatment of bacterial meningitis
in 84 adult patients. Meningitis was due to Neisseria meningitidis in 34 cases, to Streptococcus pneumoniae in 25, to Escherichia coli in three, to Klebsiella pneumoniae in two, to Haemophilus influenzae in two, to viridans streptococci in two, and to an unknown agent in 16. Eleven patients died, for an overall mortality of
13%; therapy failed in three additional cases. The mean trough levels of ceftriaxone in cerebrospinal fluid was 3.5 µg/mL;
the median trough bactericidal titer at this site was 1:128. Both our experience and that in the literature suggest that a
single daily dose is optimal when ceftriaxone is used for the treatment of bacterial meningitis.
No preview · Article · Jun 1995 · Clinical Infectious Diseases
[Show abstract][Hide abstract]ABSTRACT: Diagnosis of tuberculosis in patients infected with the human immunodeficiency virus (HIV) is sometimes difficult because
of atypical clinical and radiographic findings. The aim of this retrospective study was to determine the utility of a gallium-67
citrate scan (67Ga scan) of the chest for the early diagnosis of tuberculosis in patients infected with HIV. We selected 174 67Ga scans performed as a part of the clinical evaluation of 145 HIV-infected patients with normal pulmonary parenchyma (seen
on chest radiographs) and fever of unknown origin. Scans were evaluated as to whether there was uptake in lymphoid regions
(a positive 67Ga scan) or not (a negative scan). Tuberculosis was the most common condition associated with a positive 67Ga scan (48 [72.7%] of 66 positive 67Ga scans). Nodal uptake had a 72.7% positive predictive value and a 92.6% negative predictive value for tuberculosis. In our
experience, 67Ga scanning is a useful tool for the clinical evaluation of HIV-infected patients with unexplained fever. In areas with a
high prevalence of tuberculous infection, a 67Ga scan of an HIV-infected patient that shows nodal uptake allows the clinician to initiate prompt empirical antituberculous
therapy while waiting for culture results. Conversely, a 67Ga scan that does not show nodal uptake makes the diagnosis of tuberculosis unlikely.
[Show abstract][Hide abstract]ABSTRACT: Aztreonam and cefotaxime were compared in 44 cirrhotic patients who had 52 episodes of gram-negative spontaneous peritonitis. Patients were randomized into two therapeutic groups of similar characteristics. Group A (28 episodes) received 0.5 gm of aztreonam every 8 hr, and group B (24 episodes) received 1 gm of cefotaxime every 6 hr, for a planned 14-day period. Peak and trough serum and ascitic fluid levels of both antibiotics were several times higher than the minimum inhibitory concentrations of causative microorganisms. Eleven patients (21%) died within the first 48 hr after beginning therapy, which included seven in the aztreonam group and four in the cefotaxime group. In the remaining patients, signs and symptoms of infection were promptly controlled, and ascitic fluid cultures became negative after 48 hr in all cases, except in one patient from the aztreonam group, who was a clinical failure. Two patients from the aztreonam group and one from the cefotaxime group relapsed after treatment. The overall mortality rate was 50%, which was lower than classically reported: 12 patients (43%) died in the aztreonam group, and 14 (58%) died in the cefotaxime group (p = 0.265, NS). Hepatorenal syndrome and digestive tract hemorrhage were the most frequent causes of death occurring after the first 48 hr of treatment. Streptococcal superinfections developed in three patients (14.2%) in the aztreonam group. We conclude that both antibiotics at the low doses used in this study are similarly well tolerated and effective in controlling this infection. Because the use of aztreonam as the initial empirical treatment requires a concomitant antibiotic against gram-positive infections and the possibility of streptococcal superinfections, cefotaxime seems to be a more advantageous therapeutic alternative for this patient population.
[Show abstract][Hide abstract]ABSTRACT: We have studied gallium-67 citrate scan (Ga-67) in the diagnosis of lymphadenopathy in patients with HIV-associated symptoms. Thirty HIV-infected patients with lymphadenopathy, fever and/or weight loss were evaluated with Ga-67. Lymph-node biopsy and/or needle aspirations were done in all patients. Twelve of 17 patients with grade 2 or 3 Ga-67 (uptake equal to or greater than that in the liver) had mycobacteriosis, three had lymphoma, one had Kaposi's sarcoma plus Castleman's disease and one had follicular hyperplasia. The three patients with grade 1 Ga-67 (uptake greater than that in soft tissue but less than that in the liver) had follicular hyperplasia. Of the 10 patients with grade 0 Ga-67 (less than or equal to that in soft tissue), nine had follicular hyperplasia and one had Kaposi's sarcoma. Sixteen of 17 patients with grade 2 or 3 Ga-67 versus one of 13 with Ga-67 grade 1 or 0 had diseases other than follicular hyperplasia (P less than 0.0001). Ga-67 may be a practical diagnostic tool in HIV-infected patients with lymphadenopathy and constitutional symptoms. A grade 1 or 0 Ga-67 suggests the presence of follicular hyperplasia, and lymph-node biopsy may be avoided unless Kaposi's sarcoma is suspected.
[Show abstract][Hide abstract]ABSTRACT: Fifty evaluable patients (34 men and 16 women; mean age, 47 years) with severe infections were given intravenous ciprofloxacin (200 mg every 12 hours) for a mean of 14 days. Therapy was continued with oral ciprofloxacin 500 to 750 mg every 12 hours in 34 cases for a mean of 57 days. The sources of the infections were bone and joint (26 patients), respiratory tract (10 patients), urinary tract (four patients), soft tissue (four patients), abdominal (three patients), bacteremia of unknown origin (two patients), and right-sided endocarditis (one patient). Fifteen patients (30 percent) were bacteremic. Causative organisms included Pseudomonas aeruginosa (32 patients), other gram-negative bacilli (18 patients), and gram-positive cocci (nine patients). Minimal inhibitory concentrations ranged between 0.03 and 1 microgram/ml. Mean peak serum concentrations were 1.58 micrograms/ml (intravenous) and 2 micrograms/ml (oral); mean trough serum concentrations were 0.23 micrograms/ml (intravenous) and 0.32 micrograms/ml (oral). Serum bactericidal activity values achieved after intravenous and oral therapy were similar. Response to therapy was evaluated separately in patients with or without osteomyelitis. In 30 patients with infections other than osteomyelitis, clinical cure was achieved in 27 (90 percent), and therapy failure occurred in three patients. In the 20 remaining patients with osteomyelitis, 15 (75 percent) had a satisfactory response, with apparent cure after a mean follow-up of 11 months, whereas five had therapeutical failure (P. aeruginosa became resistant in four of them). Overall, no major adverse effects were encountered. Superinfection by a resistant P. aeruginosa was observed in three patients. Intravenous ciprofloxacin is an effective and safe agent for the therapy of severe infections caused by susceptible organisms.
No preview · Article · Dec 1989 · The American Journal of Medicine