Política de antibióticos. Comisión de Infecciones y uso de antimicrobianos

The antibiotic policy is the set of strategies and activities undertaken to organize the antimicrobial treatment in the hospital, and achieve health outcomes for patients. The basic principles are to be direct evidence-based medicine, local epidemiology and freedom for prescribing physicians. An antibiotic policy is now more necessary than ever for clinical, epidemiological and economic reasons. The Infection Committee is responsible for the antibiotics policy in hospitals. Its functions as an advisory body to the medical directorate are the analysis of the epidemiology of the infections in the center, measures for its prevention and control, improving the appropriate use of antimicrobials, training, and knowledge production. To achieve clinical, environmental and economic policy objectives of antibiotics is not easy. The agreement of hundreds of professionals for recommendations on indications, dosage and duration of antibiotic treatment, based on the best scientific evidence and local guides is complex, but it can be done. The key to this is that the Infection Committee develops antimicrobial stewardship through a multidisciplinary team and professional leadership, and has the institutional support to ensure that the proper use of antimicrobials is a priority for the center, and therefore of each of the services involved, and that the team has the resources for antimicrobial stewardship.     

Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC,SEFH y SEMPSPH

The antimicrobial agents are unique drugs for several reasons. First, their efficacy is higher than other drugs in terms of reduction of morbidity and mortality. Also, antibiotics are the only group of drugs associated with ecological effects, because their administration may contribute to the emergence and spread of microbial resistance. Finally, they are used by almost all medical specialties. Appropriate use of antimicrobials is very complex because of the important advances in the management of infectious diseases and the spread of antibiotic resistance. Thus, the implementation of programs for optimizing the use of antibiotics in hospitals (called PROA in this document) is necessary.     

Dosificación de antibióticos en el tratamiento de las infecciones por SARM en pacientes con insuficiencia renal aguda sometidos a técnicas continuas de depuración extrarrenal

Acute renal failure is frequent in critically ill patients. In those patients who need renal replacement therapy, continuous techniques are an alternative to intermittent haemodialysis. Critically ill patients often have an infection, which can lead to sepsis and renal failure. An early and adequate antibiotic treatment at correct dosage is extremely important. Methicillin resistant Staphylococcus aureus (MRSA) is a frequent nosocomial pathogen that causes a high rate of morbidity and mortality in critically ill patients.     

Infección nosocomial en el paciente receptor de un trasplante de órgano sólido o de precursores hematopoyéticos

Bacterial infections are the most common infections in solid organ transplant recipients. These infections occur mainly in the first month after transplantation and are hospital-acquired. Nosocomial infections cause significant morbidity and are the most common cause of mortality in this early period of transplantation. These infections are caused by multi-drug resistant (MDR) microorganisms, mainly Gram-negative enterobacteria, non-fermentative Gram-negative bacilli, enterococci, and staphylococci. The patients at risk of developing nosocomial bacterial infections are those previously colonized with MDR bacteria while on the transplant waiting list. Intravascular catheters, the urinary tract, the lungs, and surgical wounds are the most frequent sources of infection. Preventive measures are the same as those applied in non-immunocompromised, hospitalized patients except in patients at high risk for developing fungal infection. These patients need antifungal therapy during their hospitalization, and for preventing some bacterial infections in the early transplant period, patients need vaccinations on the waiting list according to the current recommendations. Although morbidity and mortality related to infectious diseases have decreased during the last few years in haematopoietic stem cell transplant recipients, they are still one of the most important complications in this population. Furthermore, as occurs in the general population, the incidence of nosocomial infections has increased during the different phases of transplantation. It is difficult to establish general preventive measures in these patients, as there are many risk factors conditioning these infections. Firstly, they undergo multiple antibiotic treatments and interventions; secondly, there is a wide variability in the degree of neutropenia and immunosuppression among patients, and finally they combine hospital and home stay during the transplant process. However, some simple measures could be implemented to improve the current situation.     

Características de pacientes asmáticos ingresados en una unidad de cuidados respiratorios intermedios

Introduction

Intermediate respiratory care units (IRCU) provide continuous monitoring and non-invasive mechanical ventilation (NIMV) in patients with severe respiratory failure who are usually admitted to intensive care units (ICU). The usefulness of IRCU in managing severe asthma exacerbations has never been evaluated.

Methods

Clinical data were prospectively and systematically compiled from patients admitted to the IRCU with a principal diagnosis of bronchial asthma exacerbation. We assessed therapeutic failure (intubation or exitus) and patient evolution up until 6 months after discharge compared with a group of patients admitted to a conventional hospital ward, paired for age and sex, and with the same principal diagnosis.

Results

A total of 74 asthma patients were included (37 admitted to IRCU and 37 to the hospital ward) with a mean age (± SD) of 58 ± 20 years, who were predominantly women (67%), with previous diagnosis of asthma and persistent asthma treatment. The main cause of admittance to the IRCU was severe respiratory failure. The patients who were admitted to the IRCU presented more radiological affectation (alveolar infiltrates) and had significantly higher pCO₂. Ten patients admitted to the IRCU required NIMV. There were no differences between the two groups regarding either therapeutic failure or the 6-month follow-up after discharge.

Conclusions

Patients with severe asthma exacerbations can be managed in an IRCU while avoiding hospitalization in an ICU and demonstrating a prognosis similar to milder exacerbations treated in conventional hospital wards.     

Staphylococcus coagulasa negativos resistentes al linezolid: características fenotípicas,genotípicas y sensibilidad a combinaciones de antibióticos

Objective

We recovered 22 coagulase-negative staphylococci isolates in our hospital to study their identity, susceptibility, epidemiological profile, linezolid resistance mechanisms, and the possibilities of different antibiotic combinations.

Methods

Isolate identification was performed using mass spectrometry (Vitek-MS, bioMérieux). Susceptibility testing was carried out with the Vitek-2 system and the broth microdilution method according to CLSI guidelines. Pulsed-field gel electrophoresis (PFGE) was performed to analyze the genetic relationship between isolates. Linezolid resistance mechanisms were evaluated by PCR/sequencing: presence of cfr gene, point mutations in domain V of 23S ribosomal RNA and additional ribosomal mutations (in the rplC, rplD and rplV genes).The in vitro activity of linezolid was investigated alone and in combination with another three antibiotics acting on different cellular targets, using E-test strips.

Results

Twenty isolates were identified as Staphylococcus epidermidis, and 2 as Staphylococcus hominis. PFGE showed that isolates belonged to diverse clones, 21 of them presented mutations in the domain V region of 23S rRNA and the cfr gene was found in 54.5%.Prior administration of linezolid was documented in most of cases.Linezolid in combination with gentamicin showed a synergistic activity in 45.5% of isolates.

Conclusions

Staphylococcus epidermidis was the most prevalent linezolid-resistant coagulase-negative staphylococci. All isolates showed increased MIC values compared to other anti-staphylococcal drugs and several linezolid resistance mechanisms. Our data suggest that linezolid plus gentamicin could be a synergistic combination against linezolid-resistant coagulase-negative staphylococci.     

Aumento significativo de la colonización por Staphylococcus aureus entre los estudiantes de medicina durante la realización de las prácticas en el hospital

Introduction

Staphylococcus aureus is a pathogen of major concern. The emergence of methicillin-resistant S. aureus (MRSA) has increasingly complicated the therapeutic approach of hospital-acquired infections. Surveillance of MRSA and control measures must be implemented in different healthcare settings, including screening programs for carriers. Our first aim was to determine the prevalence of methicillin-susceptible S. aureus (MSSA) and MRSA nasal carriage in medical students from the Clínico San Carlos Hospital (Madrid). As the MRSA carrier rate in healthcare workers is higher than in the general population, we hypothesised that carrier rate could be increased during their clinical practice in their last three years.

Methods

We performed an epidemiologic al study of the prevalence of S. aureus colonisation among a group of medical students, who were sampled in 2008 in their third-year, and in 2012 when this class was in its sixth year.

Results

We have found a significant increase in MSSA carriage, from 27% to 46%. There were no MRSA colonisations in the third-year, but one was found in the sixth-year group. The large majority of strains (89%) of strains were resistant to penicillin, and 27% to erythromycin and clindamycin. As 19 coagulase-negative Staphylococcus MR were also identified, a horizontal transfer of genes, such as mecA gene to S. aureus, could have occurred.

Conclusions

Medical students are both, at risk for acquiring, and a potential source of nosocomial pathogens, mainly MSSA. Therefore, they should take special care for hygienic precautions, such as frequent and proper hand washing, while working in the hospital.     

Hipertensión intraabdominal: consecuencias sobre la circulación esplácnica. Estudio preliminar en un modelo de ascitis

Introduction

Intra-abdominal hypertension is defined as a rise in intra-abdominal pressure leading to progressive dysfunction of the abdominal organs.

Objective

To evaluate the effects of intra-abdominal hypertension on the splanchnic circulation in a porcine animal model with a view to determining the diagnostic method of choice.

Material and methods

A total of 10 swine were divided into 2 groups: a control group and a group with an ascites pressure of 20 mmHg. Transvesical and transperitoneal intra-abdominal pressures were registered, and the correlation between the measurements obtained was determined. Concentrations of lactic acid, alanine aminotransferase, glucose and gastric mucosal pH were also obtained. We registered the mean arterial and abdominal perfusion pressures, and the correlation of the latter with gastric mucosal pH and lactic acid concentrations. The parameters were registered for a total of 3 hours.

Results

We observed a high correlation between transvesical and transperitoneal measurements of intra-abdominal pressure (R² = 0.98). In the 20 mmHg pressure group, lactic acid concentrations increased significantly at 180 min (p < 0.011). Gastric mucosal pH differed significantly between the 2 groups from the beginning of the study (p = 0.004) and significantly decreased from 120 min onward. Mean arterial and abdominal perfusion pressures gradually decreased during the trial, with early significant changes in the abdominal perfusion pressure (p = 0.001), and a good correlation with the remaining study parameters. There were no significant changes in hepatic indicators.

Conclusions

We believe the transvesical approach to be the technique of choice to determine intra-abdominal pressure. Abdominal perfusion pressure is a sensitive marker of intra-abdominal hypertension, and gastric mucosal pH is the first parameter to be affected.     

Actualización en cardiopatía isquémica y cuidados críticos cardiológicos

This article summarizes the main developments reported during the year 2012 concerning ischemic heart disease, together with the most relevant innovations in the management of acute cardiac patients.     

Evaluación del impacto del nuevo marco legal sanitario sobre los inmigrantes en situación irregular en España: el caso de la infección por el virus de la inmunodeficiencia humana

The immigrant population in Spain, whether legal or not, has been entitled to healthcare under the same conditions as the Spanish population since the year 2000. The entry into vigour of the Royal Decree-Law 12/2012 of 20 April has significantly restricted this right, so that unauthorized or non-resident foreigners may now only receive emergency care, if they are under 18 or pregnant women. Out of an estimated 459,909 illegal immigrants in our country, 2,700 to 4,600 are probably infected with HIV; 1,800 to 3,220 know that they are infected, and 80% of the latter could receive antiretroviral treatment. The Royal Decree-Law is likely to cause many undesirable consequences in this population infected with HIV: increasing mortality, promoting the emergence of opportunistic diseases, increasing hospital admissions, increasing infections in the population (by HIV and other pathogens), or contributing to mother to child transmission of HIV. The expected increase in morbidity and mortality will be a greater cost in patient care, a cost which will be significantly higher in the more immunosuppressed patients. Therefore, the enforcement of the Royal Decree-Law will be much less cost-effective in the short term than was expected, and will negatively affect our country's public health, especially for those patients infected with HIV who will not be covered, thus increasing healthcare medium to long term costs, and moving away from the international health goals that were established.     

Efecto de la presión positiva continua en las vías aéreas y de la cirugía de las vías aéreas superiores sobre los biomarcadores en condensado de aire exhalado y en suero en pacientes con apnea del sueño

Introduction

Studies on inflammation biomarkers in serum and in exhaled breath condensate (EBC) in obstructive sleep apnea (OSA) have shown conflicting results. The objective of this study is to assess EBC and serum biomarkers in OSA patients at baseline and after continuous positive airway pressure (CPAP) or upper airway surgery (UAS).

Patients and methods

Nine OSA patients referred for UAS were matched for anthropometric characteristics and apnea-hypopnea index with 20 patients receiving CPAP. pH, nitrite (NO₂⁻), nitrate and interleukin 6 in EBC and NO₂⁻, nitrate, leukotriene B₄ and interleukin 6 in serum were determined. EBC and serum samples were collected at baseline and 3 months after CPAP or UAS.

Results

Patients’ mean body mass index was 30 (range 24.9-40) kg/m². EBC biomarker levels at baseline were within normal range and did not differ significantly after CPAP or UAS. No significant changes were observed in the serum concentration of the biomarkers determined after CPAP but the serum concentration of NO₂⁻ increased significantly at 3 months after UAS (P = .0078).

Conclusion

In mildly obese OSA patients, EBC biomarkers of inflammation or oxidative stress were normal at baseline and remained unchanged 3 months after UAS or CPAP. Although UAS was not effective in terms of reducing OSA severity, it was associated with an increase in serum NO₂⁻.