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The number of colonoscopies performed in Spain has been progressively increasing in recent years with the program of early detection of colon cancer. The preparation for this test is the key to greater profitability and the choice of the solution to be administered, decisive. The adverse effects that we can observe; usually are mild, but they can entail other more serious ones, like electrolytic imbalances as we present in this case.

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Objetivo. Evaluar cómo han variado las decisiones de limitación del tratamiento de soporte vital (LTSV) en una unidad de cuidados intensivos (UCI) de tercer nivel a lo largo de un período de diez años. Métodos. Estudio observacional, retrospectivo y comparativo, en la UCI de un hospital universitario terciario en España, desde enero de 2005 hasta diciembre de 2014. Mediante el análisis de la base de datos informatizada del servicio, se obtuvo la muestra de enfermos en los que se realizó LTSV en el periodo descrito. Se presentan las variables categóricas como frecuencias absolutas y porcentajes, y las cuantitativas como media y desviación estándar. La χ2 se utilizó para evaluar la significación estadística de las variables categóricas y se utilizó la t de Student en las variables cuantitativas. La relación entre las variables y la decisión de LTSV se estudió mediante regresión logística. Resultados. LTSV se realizó en 409 (4,95%) a partir de 8.258 pacientes estudiados. El análisis comparativo mostró diferencias significativas entre el valor de APACHE II el día de la decisión LTSV (p=0,0001), se produjo una modificación en la distribución del tipo de LTSV, el estado de salud de los pacientes previa al ingreso en la UCI y mortalidad en la UCI en diferentes etapas. La LTSV tipo I pasó de ser el tipo de LTSV más frecuente en el año 2005, a ser el menos una década después (26,06%; IC95%: 15,60-40,26) frente a 7,32%; IC95%: 2,52-19,43). Actualmente la LTSV tipo V se ha convertido en frecuencia en la segunda opción (19,51%; IC95%: 10,23-34,01) cuando se decide la LTSV. Conclusión. Las decisiones de LTSV han cambiado la forma y las consecuencias de tomar esta decisión. Parece razonable estandarizar registros individualizados para tal finalidad (AU)

Objective. To evaluate how the decision regarding limitation of life support treatment (LLST) has varied in a tertiary ICU over a period of ten years. Methods. An observational, retrospective and comparative study of ICU patients in a tertiary university hospital in Spain from January 2005 to December 2014. Through the analysis of the unit's computerised database, we obtained the sample of patients in whom LLST was performed in the period described. The categorical variables are described as absolute frequencies and percentages, and the quantitative variables as mean and standard deviation. Chi-square was used to assess the statistical significance of categorical variables and Student's t-test was used for quantitative variables. The relationship between variables and LLST decision was studied using logistic regression. Results. LLST was performed in 409 (4.95%) of the 8,258 patients studied. The comparative analysis showed significant differences between the APACHE II values on the day of the decision regarding LLST (p=.0001), there was a change in the distribution of the type of LLST, a change in the health status of patient prior to ICU admission and ICU mortality at different stages. Type I LLST went from the most common type of LLST in 2005 to the least common a decade later (26.06%; 95% CI: 15.60-40.26 versus 7.32%; 95% CI: 2.52-19.43). Type V LLST is currently the second most common option (19.51%; 95% CI: 10.23-34.01) when deciding on LLST. Conclusion. LLST decisions have changed the way in which this decision is made and the consequences surrounding it. It seems reasonable to standardise individualised records for this purpose (AU)

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OBJECTIVES: Emergence of resistance may be prevented by killing both the parental infecting strain and subsequent less susceptible step-mutants. The present study analyses eradication and resistance selection in Streptococcus pneumoniae with moxifloxacin, levofloxacin and azithromycin, using a parental serotype 3 clinical strain (strain A) and its correspondent step-mutant derivatives resistant to these antibiotics (B, C, D), which were selected in vivo in a patient with pneumonia. METHODS: Moxifloxacin, levofloxacin and azithromycin MICs were 1, 2 and 0.5 mg/L for the parental strain; 4, 16 and 4 mg/L for isolate B; and 4, 16 and >128 mg/L for isolates C and D, respectively. A pharmacokinetic computerized device was used to simulate serum and epithelial lining fluid (ELF) concentrations. Initial inoculum was approximately 10(8) cfu/mL. Population analysis profiles were performed using plates with increasing antimicrobial concentrations. RESULTS: In ELF simulations, moxifloxacin showed a bactericidal pattern against all isolates with a minority (approximately 100 cfu/mL) of the surviving population (isolates B, C and D) growing on plates with moxifloxacin concentrations just above those in ELF. Levofloxacin and azithromycin showed a bactericidal pattern only against isolate A, with the whole population of isolates B, C and D growing on plates with levofloxacin concentrations higher (16-64 mg/L) than those in ELF and in plates with azithromycin concentrations as high as 2048 mg/L (for isolates C and D). CONCLUSIONS: Antimicrobial activity in pulmonary tissue against possible emerging resistant mutants during pneumonia treatment may prevent failures more than the solely activity against the S. pneumoniae parental infecting strain.

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OBJECTIVES: To measure the effect of opsonophagocytosis mediated by complement activated by specific antibodies on the co-amoxiclav serum bactericidal activity against Streptococcus pneumoniae strains with reduced susceptibility to beta-lactams (amoxicillin MICs of 2, 4, 8 and 16 mg/L). METHODS: An open Phase I study measuring ex vivo bactericidal activity after anti-pneumococcal vaccination and an oral dose of 2000/125 mg sustained-release co-amoxiclav was carried out. The ex vivo bactericidal activity was investigated through killing curves over 3 h [assuring polymorphonuclear neutrophil (PMN) viability] with serum samples collected 1.5 h and 5 h after dosing. Global killing was measured as the area under the killing curve (AUKC; log cfu x h/mL). The AUKC of the control growth curve of S. pneumoniae in Hanks' balanced salt solution (AUKC(K)) was used as control. The effect of the presence of complement and/or PMN was evaluated by the difference in the AUKC(K) and the different AUKCs obtained in the presence of inactivated serum (AUKC(IS)), active serum (AUKC(S)), inactivated serum plus PMN (AUKC(IS+PMN)) and active serum plus PMN (AUKC(S+PMN)). RESULTS: Significant differences were found in all cases between the bactericidal activity of active serum+PMN (AUKC(K) - AUKC(S+PMN)) and that of inactivated serum (AUKC(K) - AUKC(IS)) with therapeutic indexes ranging from 0.56 to 3.04. At 1.5 h after dosing, a significantly higher bactericidal activity of co-amoxiclav was obtained when opsonophagocytosis occurred (samples with active serum and PMN) than when not occurring (killing curves with inactivated serum and without PMN), for all amoxicillin non-susceptible strains. CONCLUSIONS: The results of this ex vivo study suggest that the collaboration of co-amoxiclav and complement-mediated opsonophagocytosis activated by specific antibodies may lay new approaches to overcome in vivo amoxicillin non-susceptibility.

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OBJECTIVES: In order to explore the pharmacodynamic need for continuous versus intermittent (three times a day) administration of ceftazidime in critically ill patients, a pharmacokinetic computerized device was used to simulate concentrations of ceftazidime in human serum after 6 g/day. METHODS: Efficacy was measured as the capability of simulated concentrations over time to reduce initial inoculum against four strains of Pseudomonas aeruginosa. MICs of the strains matched NCCLS breakpoints: one susceptible strain (MIC = 8 mg/L), two intermediate strains (MIC = 16 mg/L) and one resistant strain (MIC = 32 mg/L). C(max) was 119.97+/-2.53 mg/L for intermittent bolus and C(ss) (steady-state concentration) was 40.38+/-0.16 mg/L for continuous infusion. AUC(0-24) was similar for both regimens (approximately 950 mg x h/L). Inhibitory quotients were three times higher for the intermittent administration whereas t > MIC was higher for continuous infusion (100%) versus intermittent administration (99.8%, 69% and 47.6% for the susceptible, intermediate and resistant strains, respectively). RESULTS: Against the susceptible and intermediate strains, no differences were found between both regimens with > or = 3 log10 reduction from 8 to 24 h. Against the resistant strain, only the continuous infusion achieved this bactericidal activity in the same time period, minimizing the differences between resistant and susceptible strains. Significantly higher initial inoculum reduction at 32 h was obtained for the continuous versus the intermittent administration (83.35% versus 38.40%, respectively). CONCLUSIONS: These results stress the importance of optimizing t >MIC, even at peri-MIC concentrations, of ceftazidime against resistant strains. Local prevalence of resistance justifies, on a pharmacodynamic basis, electing for continuous infusion versus intermittent administration.

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