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BACKGROUND: The impact of co-management on clinical outcomes in neurosurgical patients is uncertain. This study aims to describe the implementation of a hospitalist co-management program in a neurosurgery department and its impact on the incidence of complications, mortality, and length of stay. METHODS: The authors used a quasi-experimental study design that compared a historical control period (July-December 2017) to a prospective intervention arm. During the intervention period, patients admitted to a neurosurgery inpatient unit who were older than 65 years, suffered certain conditions, or were admitted from ICUs were included in the co-management program. Two hospitalists joined the surgical staff and intervened in the diagnostic and therapeutical plan of patients, participating in clinical decisions and coordinating patient navigation with neurosurgeons. The incidence of moderate or severe complications measured by the Accordion Severity Grading System, in-hospital mortality, and length of stay of the two cohorts were compared. Multivariate regression was used to adjust for confounders, and the average treatment effect was estimated using inverse probability of treatment weighting. RESULTS: The adjusted incidence of moderate or severe complications was lower among co-managed patients (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.39-0.91). Mortality was unchanged (OR 0.83, 95% CI 0.15-4.17). Length of stay was lower in co-managed patients, with a 1.3-day reduction observed after inverse probability of treatment weighting analysis. CONCLUSION: Hospitalist co-management was associated with a reduced incidence of complications and length of stay in neurosurgical patients, but there was no difference in in-hospital mortality.
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Mortalidad Hospitalaria , Médicos Hospitalarios , Tiempo de Internación , Procedimientos Neuroquirúrgicos , Humanos , Tiempo de Internación/estadística & datos numéricos , Femenino , Masculino , Anciano , Complicaciones Posoperatorias/epidemiología , Persona de Mediana Edad , Estudios Prospectivos , IncidenciaRESUMEN
Background: Patient beliefs about their asthma and its treatment may contribute to overreliance on short-acting ß2-agonist (SABA) therapy, leading to increased risk for potentially life-threatening exacerbations. The SABA Reliance Questionnaire (SRQ) is a validated tool for evaluating patients beliefs about SABAs that may lead to overreliance and overuse. Objective: Our aim was to evaluate the psychometric properties of the Spanish version of the SRQ. Methods: This was an observational, cross-sectional, single-country questionnaire validation study in adults with asthma. Reliability (ordinal α) and validity (convergent and discriminant) of SRQ were evaluated. Concurrent validity was assessed with the Beliefs about Medication Questionnaire, the Treatment Satisfaction Questionnaire for Medication, and a visual analog scale item to assess patients' perceptions of the importance of their reliever inhaler. Discriminant validity was assessed through differences in mean SRQ sum score between patients with high adherence to inhaled corticosteroids and those with low adherence, as measured by the Medication Adherence Report Scale-9 and the Test of Adherence to Inhalers. Results: The Spanish-SRQ exhibited good psychometric properties among 131 patients with asthma. Internal consistency was confirmed with an ordinal α of 0.85. All 5 items were useful for measuring patients' beliefs about SABAs that may lead them to be overreliant on SABAs. Concurrent validity with the Beliefs about Medication Questionnaire, Treatment Satisfaction Questionnaire for Medication, and a visual analog scale item assessing patients' perceptions of the importance of their reliever inhaler was demonstrated. Conclusion: The Spanish version of the SRQ is a valid tool for evaluating potential overreliance on SABAs in Spanish-speaking patients to enable early intervention and support.
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A novel oxynitride Li0.94FePO3.84N0.16 with olivine structure (space group Pnma, no. 62) has been synthesized by heating a parent LiFePO4 precursor obtained by citrate chemistry in flowing ammonia at 650 °C. The polycrystalline sample has been characterized by X-ray and neutron powder diffraction (NPD), elemental and thermal analysis, scanning electron microscopy (SEM) and electrochemical measurements. Based on the existing contrast between the scattering lengths of the N and O species, a Rietveld refinement of the structure from NPD data revealed that N preferentially occupies the O2 positions, as likely required to fulfil the bonding power of N ions. The refined crystallographic formula implies an oxidation state of 2.2+ for Fe cations. The differential thermal analysis, in still air, shows a strong exothermic peak at 520-540 °C due to the combustion of C contents, which are embedding the olivine particles, as observed by SEM. The electrochemical measurements suggest a better performance for the nitrided sample relative to the unnitrided LiFePO4 material, as far as capacity and cyclability are concerned. A bond-valence energy landscape study reveals a decrease in the percolation activation energy of about 6% upon nitridation, concomitant with the better electrochemical properties of the oxynitride compound. Additionally, ceramic samples prepared under NH3 flow could be obtained as pure and well-crystallized olivine phases at milder temperatures (650 °C) than those usually described in literature.
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BACKGROUND: Controversy remains about the efficacy of tocilizumab (TCZ) for the treatment of severe COVID-19. We aimed to analyze the profile of TCZ-respondent patients. METHODS: We retrospectively analyzed a cohort of patients with severe COVID-19 who received off-label TCZ after recommendation by a local committee and were admitted to the University Hospital "12 de Octubre" until May 2020. The primary end point was a significant clinical improvement (SCI) on day 14 after administration of TCZ. Factors independently related to SCI were analyzed by multivariate logistic regression models. RESULTS: Of 428 (63.3%) patients treated with TCZ, 271 (63.3%) experienced SCI. After adjustment for factors related to unfavorable outcomes, TCZ administration within the first 48 hours from admission (odds ratio [OR]: 1.98, 95% confidence Interval [95% CI]: 1.1-3.55; P = 0.02) and ALT levels >100 UI/L at day 0 (OR: 3.28; 95% CI: 1.3-8.1; P = 0.01) were independently related to SCI. The rate of SCI significantly decreased according to the time of TCZ administration: 70.2% in the first 48 hours from admission, 58.5% on days 3-7, and 45.1% after day 7 (P = 0.03 and P = 0.001, respectively). CONCLUSION: TCZ improves the prognosis of patients with COVID-19 the most if treatment starts within the first 48 hours after admission.
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Tratamiento Farmacológico de COVID-19 , Anticuerpos Monoclonales Humanizados , Humanos , Estudios Retrospectivos , SARS-CoV-2RESUMEN
Coronavirus Disease 2019 (COVID-19) pandemic has implacably stricken on the wellness of many countries and their health-care systems. The aim of the present study is to analyze the clinical characteristics of the initial wave of patients with COVID-19 attended in our center, and to identify the key variables predicting the development of respiratory failure. Prospective design study with concurrent data retrieval from automated medical records of all hospitalized adult patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rRT-PCR assay performed on respiratory samples from March 2nd to 18th, 2020. Patients were followed up to May 1st, 2020 or death. Respiratory failure was defined as a PaO2/FiO2 ratio ≤ 200 mm Hg or the need for mechanical ventilation (either non-invasive positive pressure ventilation or invasive mechanical ventilation). We included 521 patients of whom 416 (81%) had abnormal Chest X-ray on admission. Median age was 64.6 ± 18.2 years. One hundred eighty-one (34.7%) developed respiratory failure after a median time from onset of symptoms of 9 days (IQR 6-11). In-hospital mortality was 23.8% (124/521). The modeling process concluded into a logistic regression multivariable analysis and a predictive score at admission. Age, peripheral pulse oximetry, lymphocyte count, lactate dehydrogenase and C-reactive protein were the selected variables. The model has a good discriminative capacity with an area under the ROC curve of 0.85 (0.82-0.88). The application of a simple and reliable score at admission seems to be a useful tool to predict respiratory failure in hospitalized COVID-19 patients.
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COVID-19 , Insuficiencia Respiratoria , Adulto , Anciano , Anciano de 80 o más Años , COVID-19/complicaciones , Humanos , Persona de Mediana Edad , Pandemias , Estudios Prospectivos , Insuficiencia Respiratoria/epidemiología , SARS-CoV-2RESUMEN
BACKGROUND: The role of combination immunomodulatory therapy with systemic corticosteroids and tocilizumab (TCZ) for aged patients with COVID-19-associated cytokine release syndrome remains unclear. METHODS: A retrospective single-center study was conducted on consecutive patients aged ≥65 years who developed severe COVID-19 between 03 March and 01 May 2020 and were treated with corticosteroids at various doses (methylprednisolone 0.5mg/kg/12h to 250mg/24h), either alone (CS group) or associated with intravenous tocilizumab (400-600mg, one to three doses) (CS-TCZ group). The primary outcome was all-cause mortality by day +14, whereas secondary outcomes included mortality by day +28 and clinical improvement (discharge and/or a ≥2 point decrease on a 6-point ordinal scale) by day +14. Propensity score (PS)-based adjustment and inverse probability of treatment weights (IPTW) were applied. RESULTS: Totals of 181 and 80 patients were included in the CS and CS-TCZ groups, respectively. All-cause 14-day mortality was lower in the CS-TCZ group, both in the PS-adjusted (hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.17-0.68; P=0.002) and IPTW-weighted models (odds ratio [OR]: 0.38; 95% CI: 0.21-0.68; P=0.001). This protective effect was also observed for 28-day mortality (PS-adjusted HR: 0.38; 95% CI: 0.21-0.72; P=0.003). Clinical improvement by day +14 was higher in the CS-TCZ group with IPTW analysis only (OR: 2.26; 95% CI: 1.49-3.41; P<0.001). The occurrence of secondary infection was similar between both groups. CONCLUSIONS: The combination of corticosteroids and TCZ was associated with better outcomes among patients aged ≥65 years with severe COVID-19.
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Anticuerpos Monoclonales Humanizados/administración & dosificación , Tratamiento Farmacológico de COVID-19 , Metilprednisolona/administración & dosificación , SARS-CoV-2 , Anciano , Anciano de 80 o más Años , Quimioterapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVES: A subgroup of patients with SARS-CoV-2 infection was thought to have developed cytokine release syndrome and were treated with tocilizumab; however, a significant percentage of patients evolved. This study aimed to determine the usefulness of anakinra as a rescue treatment for patients with tocilizumab-refractory COVID-19 disease. METHODS: A prospective cohort of patients with COVID-19 pneumonia who received anakinra as salvage therapy after failure of tocilizumab were compared (1:1) with selected controls in a historical cohort of patients treated with tocilizumab. Cases and controls were matched by age, comorbidities, pulse oximetry oxygen saturation to fraction of inspired oxygen (SpO2/FiO2) ratio at baseline, and time elapsed since the initiation of treatment with tocilizumab. The primary outcome was the improvement in clinical status measured by a 6-point ordinal scale, from baseline to day 21. RESULTS: The study included 20 cases and 20 controls (mean age 65.3 ± 12.8 years, 65% males). No differences were found in the clinical improvement rates at 7, 14 and 21 days of follow-up. The in-hospital mortality rate for patients receiving anakinra was 55% vs. 45% in the control group (P = 0.527). CONCLUSIONS: Treatment with anakinra was not useful in improving the prognosis of patients with tocilizumab-refractory severe COVID-19.
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Anticuerpos Monoclonales Humanizados/uso terapéutico , Tratamiento Farmacológico de COVID-19 , Síndrome de Liberación de Citoquinas/tratamiento farmacológico , Proteína Antagonista del Receptor de Interleucina 1/uso terapéutico , SARS-CoV-2 , Anciano , COVID-19/complicaciones , Estudios de Casos y Controles , Estudios de Cohortes , Síndrome de Liberación de Citoquinas/etiología , Femenino , Mortalidad Hospitalaria , Humanos , Inmunomodulación/efectos de los fármacos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Terapia Recuperativa , España/epidemiología , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
The aim of our study was to elucidate if SARS-CoV-2 viral load on admission, measured by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) cycle threshold (Ct) value on nasopharyngeal samples, was a marker of disease severity. All hospitalized adult patients with a diagnosis of SARS-CoV-2 infection by rRT-PCR performed on a nasopharingeal sample from March 1 to March 18 in our institution were included. The study population was divided according to the Ct value obtained upon admission in patients with high viral load (Ct < 25), intermediate viral load (Ct: 25-30) and low viral load (Ct > 30). Demographic, clinical and laboratory variables of the different groups were analyzed to assess the influence of viral load on the development of respiratory failure during admission. Overall, 455 sequential patients were included. The median Ct value was 28 (IQR: 24-32). One hundred and thirty patients (28.6%) had a high viral load, 175 (38.5%) an intermediate viral load and 150 (33%) a low viral load. Advanced age, male sex, presence of cardiovascular disease and laboratory markers such as lactate dehydrogenase, lymphocyte count and C-reactive protein, as well as a high viral load on admission, were predictive of respiratory failure. A Ct value < 25 was associated with a higher risk of respiratory failure during admission (OR: 2.99, 95%IC: 1.57-5.69). SARS-CoV-2 viral load, measured through the Ct value on admission, is a valuable tool to predict the development of respiratory failure in COVID-19 inpatients.
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COVID-19/complicaciones , Insuficiencia Respiratoria/virología , Carga Viral , Adulto , Anciano , Anciano de 80 o más Años , COVID-19/diagnóstico , Prueba de Ácido Nucleico para COVID-19 , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Nasofaringe/virología , Reacción en Cadena en Tiempo Real de la PolimerasaRESUMEN
Coronavirus disease 2019 (COVID-19) can lead to a massive cytokine release. The use of the anti-interleukin-6 receptor monoclonal antibody tocilizumab (TCZ) has been proposed in this hyperinflammatory phase, although supporting evidence is limited. We retrospectively analyzed 88 consecutive patients with COVID-19 pneumonia that received at least one dose of intravenous TCZ in our institution between 16 and 27 March 2020. Clinical status from day 0 (first TCZ dose) through day 14 was assessed by a 6-point ordinal scale. The primary outcome was clinical improvement (hospital discharge and/or a decrease of ≥2 points on the 6-point scale) by day 7. Secondary outcomes included clinical improvement by day 14 and dynamics of vital signs and laboratory values. Rates of clinical improvement by days 7 and 14 were 44.3% (39/88) and 73.9% (65/88). Previous or concomitant receipt of subcutaneous interferon-ß (adjusted odds ratio [aOR]: 0.23; 95% confidence interval [CI]: 0.06-0.94; P = .041) and serum lactate dehydrogenase more than 450 U/L at day 0 (aOR: 0.25; 95% CI: 0.06-0.99; P = .048) were negatively associated with clinical improvement by day 7. All-cause mortality was 6.8% (6/88). Body temperature and respiratory and cardiac rates significantly decreased by day 1 compared to day 0. Lymphocyte count and pulse oximetry oxygen saturation/FiO2 ratio increased by days 3 and 5, whereas C-reactive protein levels dropped by day 2. There were no TCZ-attributable adverse events. In this observational single-center study, TCZ appeared to be useful and safe as immunomodulatory therapy for severe COVID-19 pneumonia.
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Anticuerpos Monoclonales Humanizados/uso terapéutico , Antivirales/uso terapéutico , Tratamiento Farmacológico de COVID-19 , Síndrome de Liberación de Citoquinas/prevención & control , Factores Inmunológicos/uso terapéutico , SARS-CoV-2/patogenicidad , Administración Intravenosa , Adulto , Temperatura Corporal/efectos de los fármacos , Proteína C-Reactiva/metabolismo , COVID-19/inmunología , COVID-19/mortalidad , COVID-19/virología , Síndrome de Liberación de Citoquinas/inmunología , Síndrome de Liberación de Citoquinas/mortalidad , Síndrome de Liberación de Citoquinas/virología , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Interferón beta/efectos adversos , L-Lactato Deshidrogenasa/sangre , Masculino , Persona de Mediana Edad , Receptores de Interleucina-6/antagonistas & inhibidores , Receptores de Interleucina-6/genética , Receptores de Interleucina-6/inmunología , Frecuencia Respiratoria/efectos de los fármacos , Estudios Retrospectivos , SARS-CoV-2/inmunología , Índice de Severidad de la Enfermedad , Análisis de SupervivenciaRESUMEN
BACKGROUND: We aimed to analyze the impact of cefotaxime non-susceptibility on the 30-day mortality rate in patients receiving a third-generation cephalosporin for pneumococcal bacteremic pneumonia. METHODS: We conducted a retrospective observational study of prospectively collected data from the Hospital Clinic of Barcelona. All adult patients with monomicrobial bacteremic pneumonia due to Streptococcus pneumoniae and treated with a third-generation cephalosporin from January 1991 to December 2016 were included. Risk factors associated with 30-day mortality were evaluated by univariate and multivariate analyses. RESULTS: During the study period, 721 eligible episodes were identified, and data on the susceptibility to cefotaxime was obtainable for 690 episodes. Sixty six (10%) cases were due to a cefotaxime non-susceptible strain with a 30-day mortality rate of 8%. Variables associated with 30-day mortality were age, chronic liver disease, septic shock, and the McCabe score. Infection by a cefotaxime non-susceptible S. pneumoniae did not increase the mortality rate. CONCLUSION: Despite the prevalence of cefotaxime, non-susceptible S. pneumoniae has increased in recent years. We found no evidence to suggest that patients hospitalized with bacteremic pneumonia due to these strains had worse clinical outcomes than patients with susceptible strains.
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BACKGROUND: More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. The aims of this study were to investigate predictors of de-escalation and its impact on the outcome of patients with bloodstream infection due to Enterobacteriaceae (BSI-E). METHODS: A post hoc analysis was performed on a prospective, multicenter cohort of patients with BSI-E initially treated with ertapenem or antipseudomonal ß-lactams. Logistic regression was used to analyze factors associated with early de-escalation (EDE) and Cox regression for the impact of EDE and late de-escalation (LDE) on 30-day all-cause mortality. A propensity score (PS) for EDE vs no de-escalation (NDE) was calculated. Failure at end of treatment and length of hospital stay were also analyzed. RESULTS: Overall, 516 patients were included. EDE was performed in 241 patients (46%), LDE in 95 (18%), and NDE in 180 (35%). Variables independently associated with a lower probability of EDE were multidrug-resistant isolates (odds ratio [OR], 0.50 [95% confidence interval {CI}, .30-.83]) and nosocomial infection empirically treated with imipenem or meropenem (OR, 0.35 [95% CI, .14-.87]). After controlling for confounders, EDE was not associated with increased risk of mortality; hazard ratios (HR) (95% CIs) were as follows: general model, 0.58 (.25-1.31); model with PS, 0.69 (.29-1.65); and PS-based matched pairs, 0.98 (.76-1.26). LDE was not associated with mortality. De-escalation was not associated with clinical failure or length of hospital stay. CONCLUSIONS: De-escalation in patients with monomicrobial bacteremia due to Enterobacteriaceae was not associated with a detrimental impact on clinical outcome.
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Bacteriemia , Infecciones por Enterobacteriaceae/microbiología , Infecciones por Enterobacteriaceae/mortalidad , Enterobacteriaceae , Anciano , Enterobacteriaceae/efectos de los fármacos , Enterobacteriaceae/genética , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Infecciones por Enterobacteriaceae/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Oportunidad Relativa , Pronóstico , Modelos de Riesgos Proporcionales , Estudios ProspectivosRESUMEN
BACKGROUND: Ceftazidime-avibactam has in vitro activity against Gram-negative bacilli that produce Class A, C and some D ß-lactamases, and has been successfully used in the treatment of infections caused by cephalosporin and carbapenem-resistant Enterobacteriaceae. However, actual experience in the treatment of OXA-48 carbapenemase-producing Enterobacteriaceae (CPE) is limited. OBJECTIVE: To review the characteristics and prognosis of OXA-48 CPE infections treated with ceftazidime-avibactam since introduction of the drug to the current centre during the period October 2014 to December 2016. METHODS: Retrospective assessment of episodes of infection caused by OXA-48 CPE treated with ceftazidime-avibactam, analysing data collected from infection diagnosis until 90 days after the end of treatment. RESULTS: Twenty-four episodes were analysed. Ceftazidime-avibactam was given as the initial definitive treatment in 15 (62.5%) and as salvage therapy in nine (37.5%). Intraabdominal (seven, 29%), urinary (six, 25%) and respiratory (five, 21%) were the most common sources. The 30-day and 90-day mortality rates were 8.3% and 20.8%, respectively. Clinical cure at 30 days was achieved in 62.5% of episodes. Four (16.7%) patients had adverse events, two of them were related to impaired renal function. Among patients who finished the treatment with ceftazidime-avibactam, seven (35%) were diagnosed with infection recurrence within 90 days of the end of treatment. CONCLUSIONS: From experience, ceftazidime-avibactam is an effective drug for treating infections due to OXA-48 CPE. From these results a better safety profile than the current best available therapy could be expected.
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Antibacterianos/uso terapéutico , Compuestos de Azabiciclo/uso terapéutico , Enterobacteriaceae Resistentes a los Carbapenémicos/efectos de los fármacos , Ceftazidima/uso terapéutico , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Infecciones por Enterobacteriaceae/mortalidad , Inhibidores de beta-Lactamasas/uso terapéutico , beta-Lactamasas/metabolismo , Enterobacteriaceae Resistentes a los Carbapenémicos/aislamiento & purificación , Combinación de Medicamentos , Farmacorresistencia Bacteriana Múltiple , Infecciones por Enterobacteriaceae/microbiología , Femenino , Humanos , Klebsiella pneumoniae/efectos de los fármacos , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Terapia Recuperativa/métodosRESUMEN
OBJECTIVES: The steady progress in resistance of Pseudomonas aeruginosa (PA) has led to difficulties in treating infections due to multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains. Ceftazidime/avibactam (CAZ/AVI) has in vitro activity against many of these strains, however clinical experience with CAZ/AVI is limited. This study aimed to evaluate the characteristics and outcomes of eight patients with infections due to MDR- or XDR-PA treated with CAZ/AVI, including four strains resistant to ceftolozane/tazobactam. METHODS: This was a retrospective descriptive study of patients admitted to a teaching hospital between January 2016 and May 2017 who received CAZ/AVI as initial or continuation therapy for infection due to MDR- and XDR-PA. RESULTS: The sources of infection were hospital-acquired lower respiratory tract infection in five patients (62.5%) and osteomyelitis, meningitis and catheter-related bacteraemia in one patient each. Clinical cure was achieved in 4 patients (50.0%). The 30-day and 90-day mortality rates were 12.5% and 37.5%, respectively. One patient (12.5%) developed encephalopathy that improved with discontinuation of the drug. CONCLUSIONS: CAZ/AVI may be a valuable option for serious infections due to resistant PA.
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Antibacterianos/uso terapéutico , Compuestos de Azabiciclo/uso terapéutico , Ceftazidima/uso terapéutico , Farmacorresistencia Bacteriana Múltiple , Infecciones por Pseudomonas/tratamiento farmacológico , Pseudomonas aeruginosa/efectos de los fármacos , Anciano , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Retrospectivos , Centros de Atención Terciaria , Resultado del TratamientoRESUMEN
OBJECTIVETo compare the epidemiology, clinical characteristics, and mortality of patients with bloodstream infections (BSI) caused by extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli (ESBL-EC) versus ESBL-producing Klebsiella pneumoniae (ESBL-KP) and to examine the differences in clinical characteristics and outcome between BSIs caused by isolates with CTX-M versus other ESBL genotypesMETHODSAs part of the INCREMENT project, 33 tertiary hospitals in 12 countries retrospectively collected data on adult patients diagnosed with ESBL-EC BSI or ESBL-KP BSI between 2004 and 2013. Risk factors for ESBL-EC versus ESBL-KP BSI and for 30-day mortality were examined by bivariate analysis followed by multivariable logistic regression.RESULTSThe study included 909 patients: 687 with ESBL-EC BSI and 222 with ESBL-KP BSI. ESBL genotype by polymerase chain reaction amplification of 286 isolates was available. ESBL-KP BSI was associated with intensive care unit admission, cardiovascular and neurological comorbidities, length of stay to bacteremia >14 days from admission, and a nonurinary source. Overall, 30-day mortality was significantly higher in patients with ESBL-KP BSI than ESBL-EC BSI (33.7% vs 17.4%; odds ratio, 1.64; P=.016). CTX-M was the most prevalent ESBL subtype identified (218 of 286 polymerase chain reaction-tested isolates, 76%). No differences in clinical characteristics or in mortality between CTX-M and non-CTX-M ESBLs were detected.CONCLUSIONSClinical characteristics and risk of mortality differ significantly between ESBL-EC and ESBL-KP BSI. Therefore, all ESBL-producing Enterobacteriaceae should not be considered a homogeneous group. No differences in outcomes between genotypes were detected.CLINICAL TRIALS IDENTIFIERClinicalTrials.gov. Identifier: NCT01764490.Infect Control Hosp Epidemiol 2018;39:660-667.
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Bacteriemia/microbiología , Bacteriemia/mortalidad , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Infecciones por Escherichia coli/mortalidad , Infecciones por Klebsiella/mortalidad , Adulto , Anciano , Escherichia coli/enzimología , Escherichia coli/genética , Femenino , Genotipo , Registros de Hospitales , Humanos , Klebsiella pneumoniae/enzimología , Klebsiella pneumoniae/genética , Modelos Logísticos , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Centros de Atención Terciaria , beta-Lactamasas/metabolismoRESUMEN
OBJECTIVES: To evaluate the influence on mortality of empirical double-active combination antimicrobial therapy (DACT) compared with active monotherapy (AM) in septic shock patients. METHODS: A retrospective study was performed of monomicrobial septic shock patients admitted to a university centre during 2010-15. A propensity score (PS) was calculated using a logistic regression model taking the assigned therapy as the dependent variable, and used as a covariate in multivariate analysis predicting 7, 15 and 30 day mortality and for matching patients who received DACT or AM. Multivariate models comprising the assigned therapy group and the PS were built for specific patient subgroups. RESULTS: Five-hundred and seventy-six patients with monomicrobial septic shock who received active empirical antimicrobial therapy were included. Of these, 340 received AM and 236 DACT. No difference in 7, 15 and 30 day all-cause mortality was found between groups either in the PS-adjusted multivariate logistic regression analysis or in the PS-matched cohorts. However, in patients with neutropenia, DACT was independently associated with a better outcome at 15 (OR 0.29, 95% CI 0.09-0.92) and 30 (OR 0.25, 95% CI 0.08-0.79) days, while in patients with Pseudomonas aeruginosa infection DACT was associated with lower 7 (OR 0.12, 95% CI 0.02-0.7) and 30 day (OR 0.26, 95% CI 0.08-0.92) mortality. CONCLUSIONS: All-cause mortality at 7, 15 and 30 days was similar in patients with monomicrobial septic shock receiving empirical double-active combination therapy and active monotherapy. However, a beneficial influence of empirical double-active combination on mortality in patients with neutropenia and those with P. aeruginosa infection is worthy of further study.
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Antiinfecciosos/administración & dosificación , Infecciones Bacterianas/tratamiento farmacológico , Infecciones Bacterianas/mortalidad , Quimioterapia Combinada/métodos , Choque Séptico/tratamiento farmacológico , Choque Séptico/mortalidad , Centros Médicos Académicos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: We aimed to investigate the association between the time to positivity of blood culture (TTP) with clinical outcome and severity of pneumococcal bacteremic pneumonia. METHODS: Prospective observational study carried out in 278 hospitalized adult CAP patients with positive blood culture for Streptococcus pneumonia (2003-2015). RESULTS: A total of 278 cases of bacteremic pneumococcal pneumonia were analyzed, median age 62 (46; 79) years. Fifty-one percent of the cases had PSI IV-V. Twenty-one (8%) died within 30-days after admission. The analysis of the TTP showed that the first quartile of the TTP (9.2h) was the best cut-off for differentiating 2 groups of patients at risk, early (TTP <9.2 h) and late (TTP ≥9.2 h) detection groups (AUC 0.66 [95% CI 0.53 to 0.79]). Early TTP was associated with a statistically significant risk of invasive mechanical ventilation (18% vs. 6%, p = 0.007), longer length of hospital stay (12 days vs. 8 days, p<0.001), higher in-hospital mortality (15% vs. 4%, p = 0.010), and 30-day mortality (15% vs. 5%, p = 0.018). After adjustment for potential confounders, regression analyses revealed early TTP as independently associated with high risk of invasive mechanical ventilation (OR 4.60, 95% CI 1.63 to 13.03), longer length of hospital stay (ß 5.20, 95% CI 1.81 to 8.52), higher in-hospital mortality (OR 5.35, 95% CI 1.55 to 18.53), and a trend to higher 30-day mortality (OR 2.47, 95% CI 0.85 to 7.21) to be a contributing factor. CONCLUSION: Our results demonstrate that TTP is an easy to obtain surrogate marker of the severity of pneumococcal pneumonia and a good predictor of its outcome.
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Bacteriemia/complicaciones , Cultivo de Sangre , Neumonía Neumocócica/sangre , Neumonía Neumocócica/diagnóstico , Anciano , Infecciones Comunitarias Adquiridas/sangre , Infecciones Comunitarias Adquiridas/complicaciones , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Admisión del Paciente/estadística & datos numéricos , Neumonía Neumocócica/complicaciones , Neumonía Neumocócica/mortalidad , Pronóstico , Respiración Artificial , Factores de TiempoRESUMEN
Introduction. The aim of this study was to determine the usefulness of oxidase test and time-to-positivity (TTP) in aerobic and anaerobic blood culture vials to detect the presence of Pseudomonas aeruginosa in patients with Gram-negative bacilli (GNB) bacteraemia. Material and methods. TTP was recorded for each aerobic and anaerobic blood culture vial of monomicrobial bacteraemia due to GNB. Oxidase test was performed in a pellet of the centrifuged content of the positive blood culture. An algorithm was developed in order to perform the oxidase test efficiently taking into account TTP and type of vial. Results. A total of 341 episodes of GNB bacteraemia were analysed. Sensitivity, specificity, positive predictive value and negative predictive value of the oxidase test performed on positive vials with GNB to predict P. aeruginosa were 95%, 99%, 91%, and 99%, respectively. When growth was first or exclusively detected in anaerobic vials, P. aeruginosa was never identified hence the performance of the oxidase test could be avoided. When growth was only or first detected in aerobic vials, a TTP≥8h predicted P. aeruginosa in 37% or cases (63 of 169), therefore oxidase test is highly recommended. Conclusions. Oxidase test performed onto positive blood culture vials previously selected by TTP and type of vials is an easy and inexpensive way to predict P. aeruginosa. In most cases, this can lead to optimization of treatment in less than 24 hours (AU)
Introducción. El objetivo del estudio fue determinar la utilidad de la prueba de oxidasa y del tiempo de positividad del hemocultivo (TPH) para detectar la presencia de Pseudomonas aeruginosa en pacientes con bacteriemia por bacilos gramnegativos (BGN). Material y métodos. Se registró el TPH de cada vial aerobio y anaerobio en todos los episodios de bacteriemia monomicrobiana por BGN. La prueba de oxidasa se realizó sobre el contenido centrifugado del hemocultivo positivo. Se diseñó un algoritmo para optimizar la realización de la prueba de oxidasa según el TPH y el tipo de vial. Resultados. Se analizaron 341 episodios de bacteriemia por BGN. La sensibilidad, especificidad, valor predictivo positivo y valor predictivo negativo de la prueba de oxidasa para predecir P. aeruginosa fueron del 95%, 99%, 91% y 99%, respectivamente. Cuando el crecimiento se detectó primero o exclusivamente en viales anaerobios, nunca se identificó P. aeruginosa pudiendo evitar la realización de la prueba de oxidasa. Cuando el crecimiento se detectó antes o exclusivamente en viales aerobios un TPH ≥8h predijo la presencia de P. aeruginosa en el 37% de los casos (63 de 169), por lo que es recomendable la realización de la prueba de oxidasa. Conclusiones. La prueba de oxidasa realizada a viales de hemocultivos positivos previamente seleccionados por el TPH y el tipo de medio es una forma fácil y económica de predecir P. aeruginosa. En la mayoría de los casos, esto puede contribuir a la optimización del tratamiento antibiótico en menos de 24h (AU)
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Humanos , Masculino , Femenino , Medios de Cultivo/síntesis química , Medios de Cultivo/farmacología , Medios de Cultivo/farmacocinética , Técnicas de Cultivo/métodos , Pseudomonas aeruginosa , Bacteriemia/tratamiento farmacológico , Bacteriemia/microbiología , Oxidorreductasas/análisis , Oxidorreductasas/farmacología , Bacilos y Cocos Aerobios Gramnegativos , Bacilos y Cocos Aerobios Gramnegativos/aislamiento & purificación , Algoritmos , Sensibilidad y Especificidad , Técnicas y Procedimientos Diagnósticos/tendenciasRESUMEN
Catheter-related bacteremia (CRB) is an important cause of morbidity and mortality among hospitalized patients, being staphylococci the main etiologic agents. The objective of this study was to assess the use of a PCR-based assay for detection of staphylococci directly from blood obtained through the catheter to diagnose CRB caused by these microorganisms and to perform a cost-effectiveness analysis. A total of 92 patients with suspected CRB were included in the study. Samples were obtained through the catheter. Paired blood cultures were processed by standard culture methods and 4 ml blood samples were processed by GeneXpert-MRSA assay for the detection of methicillin-susceptible (MSSA) or methicillin-resistant (MRSA) Staphylococcus aureus, and methicillin-resistant coagulase-negative staphylococci (MR-CoNS). Sixteen CRB caused by staphylococci were diagnosed among 92 suspected patients. GeneXpert detected 14 out of 16 cases (87.5%), including 4 MSSA and 10 MR-CoNS in approximately 1 hour after specimen receipt. The sensitivity and specificity of GeneXpert were 87.5% (CI 95%: 60.4-97.8) and 92.1% (CI 95%: 83-96.7), respectively, compared with standard culture methods. The sensitivity of GeneXpert for S. aureus was 100%. Regarding a cost-effectiveness analysis, the incremental cost of using GeneXpert was of 31.1 per patient while the incremental cost-effectiveness ratio of GeneXpert compared with blood culture alones was about 180 per life year gained. In conclusion, GeneXpert can be used directly with blood samples obtained through infected catheters to detect S. aureus and MR-CoNS in approximately 1h after sampling. In addition, it is cost-effective especially in areas with high prevalence of staphylococcal CRB.
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Bacteriemia/diagnóstico , Bacteriemia/etiología , Catéteres de Permanencia/microbiología , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/etiología , Staphylococcus aureus/patogenicidad , Bacteriemia/microbiología , Humanos , Resistencia a la Meticilina , Staphylococcus aureus Resistente a Meticilina/patogenicidad , Pruebas de Sensibilidad Microbiana , Reacción en Cadena en Tiempo Real de la Polimerasa , Infecciones Estafilocócicas/microbiología , Staphylococcus aureus/efectos de los fármacos , Staphylococcus aureus/genéticaRESUMEN
OBJECTIVES: To evaluate characteristics and prognostic factors of community-onset bloodstream infection (Co-BSI) in elderly patients (≥65 years). METHODS: Analysis of a prospective series of Co-BSI at a tertiary hospital (2005-2011). Predictors of 30-day mortality were established by logistic regression analysis. RESULTS: A total of 2605 episodes of Co-BSI were identified and empirical antibiotic treatment was inappropriate in 404 (15.5%). Thirty-day mortality was 11.4% and was independently associated with age (75-84 years OR 1.9, 1.37-2.67; ≥85 OR 2.85, 1.93-4.21), previous hospitalization (OR 1.45, 1.05-2.00), a fatal underlying disease (OR 2.81, 2.10-3.76), neutropenia (OR 2.62, 1.54-4.43), absence of fever (OR 1.99, 1.26-3.12), shock (OR 7.96, 5.83-10.89), inappropriate empirical treatment (OR 1.49, 1.03-2.16), isolation of Staphylococcus aureus (methicillin-resistant OR 2.83, 1.38-5.78; methicillin-susceptible OR 3.24, 1.98-5.32), enterococci (OR 2.02, 1.14-3.59) or Enterobacteriaceae resistant to third-generation cephalosporin (3GCR-E) (OR 1.96, 1.16-3.32) and having endovascular non-catheter (OR 4.64, 2.51-8.59), abdominal (OR 3.65, 2.12-6.27), skin/soft tissue (OR 3.48, 1.90-6.37), respiratory (OR 2.80, 1.75-4.50) or unknown (OR 1.83, 1.17-2.87) source. CONCLUSIONS: Age is a prognostic factor and appropriateness of empirical treatment is the only modifiable variable. S. aureus, enterococci and 3GCR-E may be the microorganisms with major prognostic significance; hence efforts should be made to improve their management.