Optimizing Process of Care in Community-Acquired Pneumonia

Optimització dels processos; Pneumònia adquirida a la comunitat; Salut comunitàriaProcess optimization; Community-acquired pneumonia; Community healthOptimización de los procesos; Neumonía adquirida en la comunidad; Salud comunitariaLa comunicació presenta una de les línies de recerca a l'Hospital de Bellvitge al voltant de les malalties infeccioses i la resistència als fàrmacs antimicrobians: l'optimització del procés d'atenció en pneumònies adquirides a la comunitat. Presentació d'estudis i resultats

La crisi dels antibiòtics

Crisi; Antibiòtics; Resistència als antimicrobiansCrisis; Antibióticos; Resistencia a los antimicrobianosCrisis; Antibiotics; Resistance to antimicrobialsComunicació que repassa la història dels antibiòtics i la resistència als fàrmacs antimicrobians

Meningitis neumocócica del adulto, 1977-1989: Impacto de la resistencia antibiótica. Estudio de los factores pronósticos y de nuevos aspectos terapéuticos

[spa] En 1977 iniciamos un proyecto de investigación clínica en torno a las infecciones del SNC, parte del cual consistió en la elaboración de un protocolo de estudio de las meningitis bacterianas. Trece años después, a finales de 1989, habían sido incluidos definitivamente en el protocolo 797 episodios de meningitis, entre los cuales se hallaban 132 episodios de meningitis neumocócica, objeto del presente estudio.La meningitis neumocócica del adulto despertó desde el principio nuestro interés debido a su especial gravedad y a las dificultades existentes en su tratamiento. Nos preocupó fundamentalmente que su pronóstico, en cuanto a mortalidad y desarrollo de secuelas neurológicas en los supervivientes, apenas hubiese mejorado en los últimos treinta años, a pesar de la introducción de nuevos antibióticos con gran actividad bactericida. La ulterior aparición y aumento progresivo del número de cepas de neumococo resistentes a la penicilina y a otros antibióticos supuso otra complicación adicional para el manejo adecuado de estos pacientes.Los objetivos concretos de nuestro estudio fueron:l. - Delimitar la situación actual de la meningitis neumocócica en el contexto de la meningitis bacteriana del adulto.2.- Conocer la actividad "in vitro" de los antimicrobianos frente a las cepas de "S. pneumoniae" causantes de meningitis.3. - Determinar la epidemiología y las características clínicas y evolutivas de la meningitis causada por neumococos resistentes a la penicilina en nuestro medio.4.- Establecer el papel de la penicilina G, cefalosporinas de tercera generación y vancomicina en el tratamiento de la meningitis causada por neumococos resistentes.5.- Determinar los factores pronósticos de la meningitis neumocócica.6. - Evaluar la influencia del tratamiento asociado en la evolución de la meningitis neumocócica.Los datos de los pacientes, tanto clínicos como de laboratorio, fueron recogidos en un protocolo informatizado de 115 variables, definidas previamente, rellenado una vez que el paciente era dado de alta y completado tras el seguimiento en consultas externas. Con posterioridad los datos se incluyeron en una base de datos (DBase III plus) y fueron explotados estadísticamente.Se realizó un análisis multivariado de la mortalidad global y de la atribuible directamente a la infección.Las intervenciones más importantes efectuadas fueron la introducción de las cefalosporinas de 3ª generación, como tratamiento antibiótico inicial en 1986 y la administración precoz y sistemática de manitol, dexametasona y difenilhidantoina, como tratamiento asociado a los antibióticos.Se realizó un estudio caso-control "matched" para analizar la influencia del tratamiento asociado a los antibióticos en la reducción de la mortalidad. Los cálculos estadísticos se realizaron en un microordenador mediante los paquetes SPSS y BMOP.Las principales conclusiones del estudio fueron:En nuestra comunidad, el neumococo es causa de una cuarta parte del total de casos de meningitis bacteriana, y de la mitad de aquellos casos que cursan sin púrpura. .En un 80-85% de pacientes con meningitis neumocócica puede detectarse el foco de origen de la infección, hecho que ocurre con mucha menor frecuencia en el resto de etiologías. En consecuencia, alrededor de las tres cuartas partes de casos de meningitis de la comunidad asociados a otitis media aguda, sinusitis, neumonía ó fístula de LCR, van a ser de etiología neumocócica.El neumococo es causa poco frecuente de meningitis nosocomial, habiendo originado un 7% de nuestros casos.La meningitis neumocócica sigue siendo una enfermedad muy grave, de peor pronóstico que la ocasionada por otros patógenos meníngeos clásicos como meningococo ó hemofilus. En nuestra serie, su tasa de mortalidad específica fue del 29%, sólo superada por la de los bacilos Gram negativos. Asimismo, en cifras absolutas, fue la etiología que ocasionó un mayor número de fallecimientos.La resistencia del neumococo a la penicilina ha aumentado de forma progresiva durante el período de estudio, tanto en frecuencia como en grado.El porcentaje global de resistencia en nuestra serie ha sido del 27,5%.En la actualidad, estimamos que la probabilidad de que una meningitis neumocócica sea causada por una cepa con sensibilidad disminuida a la penicilina es el 50%, y que la mitad de las cepas con sensibilidad disminuida son altamente resistentes.Asimismo, la probabilidad de resistencia al cloramfenicol y al cotrimoxazol es de 35 % y 50 %, respectivamente.El 75 % de las cepas resistentes a penicilina muestran resistencia múltiple. La cefotaxima, la ceftriaxona y el imipeném son los antibióticos betalactámicos más activos frente a los neumococos resistentes a la penicilina. No hemos hallado cepas de neumococo resistentes a la vancomicina ni a la rifampicina.No observamos diferencias importantes (epidemiológicas, clínicas y evolutivas), entre los casos de meningitis causados por neumococos sensibles ó resistentes a la penicilina. Sin embargo, los casos resistentes con mayor frecuencia fueron ocasionados por el serotipo 23, eran de adquisición nosocomial, y habían recibido antibióticos previos.La penicilina debe reservarse exclusivamente para el tratamiento de las meningitis causadas por neumococos sensibles, puesto que ni con la utilización de dosis masivas puede garantizarse la curación bacteriológica de los casos con resistencia moderada.La cefotaxima y la ceftriaxona constituyen el tratamiento de elección de la meningitis neumocócica, antes de conocer la sensibilidad de la cepa causal. Ambas se han mostrado eficaces en los casos causados por neumococos con CBMs a la penicilina de hasta 4 mcg/ml.La vancomicina no debe ser utilizada como tratamiento de rutina de la meningitis causada por neumococos resistentes r debido a su alto índice de recaídas.Debe reservarse para casos de alta resistencia que no hayan respondido a la cefotaxima y para casos seleccionados de alergia a betalactámicos, siempre que sean resistentes al cloramfenicol.Los factores que se asociaron de forma independiente con una mayor mortalidad global fueron: la presencia de shock al ingreso (RR 8.1), la edad superior a 65 años (RR 4.6), el desarrollo de complicaciones pulmonares durante el ingreso (RR 4.6) y el que la infección hubiese tenido un foco de origen distante del SNC (RR 3.3).Los factores que se asociaron de forma independiente con una mayor mortalidad por la propia infección fueron: la presencia de shock al ingreso (RR 4.73) y el que la infección hubiese tenido un foco de origen distante del SNC (RR 4.4).En el subgrupo de pacientes con meningitis de foco de origen contiguo al SNC, sólo el desarrollo de convulsiones tras el ingreso (RR 4.9) se asoció de forma independiente con una mayor mortalidad por la propia infección.Mediante la administración sistemática y precoz de manital, dexametasona y difenilhidantoina, como tratamiento asociado a los antibióticos, conseguimos reducir muy significativamente la mortalidad de nuestros pacientes.Así pues, concluimos que la utilización de dicho tratamiento asociado parece constituir un gran avance en el manejo de los pacientes con meningitis neumocócica.[eng] We studied 132 episodes of adult pneumococcal meningitis (PM) as a part of a prospective study involving 797 cases of' bacterial meningitis observed from 1977 to 1989. The main objectives were: l) to know the "in vitro" activity of' different antimicrobial agents against the strains of pneumococci in our area, 2) to know the epidemiology, characteristics and outcome of the PM due to resistant strains, 3) to determine the best therapy for such infections, 4): to determine the prognostic factors of PM, and 5) to evaluate the effects of an adjunctive therapy on the outcome.We observed a sustained tendency towards increasing resistance of pneumococci to peniciline, cloramphenicol and cotrimoxazol. The current penicillin and cloranphenicol resistances approach 50%. The recommended initial therapy for a PM in our area is Cefrotaxime in doses of 300 mg/Kg/day. The major independent factors influencing mortality are the age of patients, the presence of shock on admission and the source of the infection. The early administration of manitol, dexamethasone and phenytoin as an adjunctive therapy to antibiotics, reduced significantly the mortality (from 30 to 5%) and thus appears to be a major advance in the therapy of PM

Drug-resistant Streptococcus pneumoniae

To the Editor: since the first description of infection caused by β-lactam-resistant Streptococcus pneumoniae, the optimal empirical antibiotic therapy for patients with suspected meningitis caused by this microorganism has remained unknown. Hofmann et al. (Aug. 24 issue)1 reported a 25 percent prevalence of penicillin-resistant S. pneumoniae isolates and a 9 percent prevalence of cephalosporin-resistant isolates among 431 patients with invasive pneumococcal infections in Atlanta. The authors recommended adding vancomycin to the initial therapeutic regimen of patients with suspected pneumococcal meningitis

Current Challenges in the Management of Infective Endocarditis

Infective endocarditis is a relatively rare, but deadly cause of sepsis, with an overall mortality ranging from 20 to 25% in most series. Although the classic clinical classification into syndromes of acute or subacute endocarditis have not completely lost their usefulness, current clinical forms have changed according to the profound epidemiological changes observed in developed countries. In this review, we aim to address the changing epidemiology of endocarditis, several recent advances in the understanding of the pathophysiology of endocarditis and endocarditis-triggered sepsis, new useful diagnostic tools as well as current concepts in the medical and surgical management of this disease. Given its complexity, the management of infective endocarditis requires the close collaboration of multidisciplinary endocarditis teams that must decide on the diagnostic approach; the appropriate initial treatment in the critical phase; the detection of patients needing surgery and the timing of this intervention; and finally the accurate selection of patients for out-of-hospital treatment, either at home hospitalization or with oral antibiotic treatment

Risk Factors for Nosocomial Bacterremia Due to Methicillin-Resistant Staphylococcus Aureus

In a prospective surveillance study (February 1990–December 1991) performed at a 1000-bed teaching hospital to identify risk factors for nosocomial methicillin-resistantStaphylococcus aureus (MRSA) bacteremia, 309 patients were found to be colonized (n=103; 33 %) or infected (n=206; 67 %) by MRSA. Sixty-three of them developed bacteremia. Compared with 114 patients who had nosocomial bacteremia caused by methicillin-sensitiveStaphylococcus aureus during the same period of time, MRSA bacteremic patients had more severe underlying diseases (p<0.01), were more often in intensive care units (p<0.01) and had received prior antibiotic therapy more frequently (p<0.01). To further identify risk factors for MRSA bacteremia, univariate and multivariate analyses of this series of 309 patients were performed using the occurrence of MRSA bacteremia as the dependent variable. Among 14 variables analyzed, intravascular catheterization, defined as one or more intravascular catheters in place for more than 48 h, was the only variable selected by a logistic regression model as an independent risk factor (OR=2.7, CI=1.1–6.6). The results of this study reinforce the concept that recent antibiotic therapy may predispose patients to MRSA infection and suggest that among patients colonized or infected by MRSA, those with intravascular catheters are at high risk of developing MRSA bacteremia

Nosocomial Staphylococcus Aureus Bacterimia among Nasal Carriers of Methicillin- Resistant and Methicillin-Susceptible Strains

Objectives To determine the relevance of nasal carriage of Staphylococcus aureus, either methicillin-sensitive (MSSA) or methicillinresistant (MRSA), as a risk factor for the development of nosocomial S aureus bacteremia during an MRSA outbreak. patients and methods: In this prospective cohort study, 488 patients admitted to an intensive care unit (ICU) during a 1-year period were screened with nasal swabs within 48 hours of admission and weekly thereafter in order to identify nasal S aureus carriage. Nasal staphylococcal carriers were observed until development of S aureus bacteremia, ICU discharge, or death. Results One hundred forty-seven (30.1%) of 488 patients were nasal S aureus carriers; 84 patients (17.2%) harbored methicillin-sensitive S aureus; and 63 patients (12.9%) methicillinresistant S aureus. Nosocomial S aureus bacteremia was diagnosed in 38 (7.7%) of 488 patients. Rates of bacteremia were 24 (38%) of the MRSA carriers, eight (9.5%) of the MSSA carriers, and six (1.7%) of noncarriers. After adjusting for other predictors of bacteremia by means of a Cox proportional hazard regression model, the relative risk for S aureus bacteremia was 3.9 (95% confidence interval, 1.6–9.8; P = 0.002) for MRSA carriers compared with MSSA carriers. Conclusions Among ICU patients, nasal carriers of S aureus are at higher risk for S aureus bacteremia than are noncarriers; in the setting of an MRSA outbreak, colonization by methicillin-resistant strains represents a greater risk than does colonization by MSSA and strongly predicts the occurrence of MRSA bacteremia

Rainfall is a risk factor for sporadic cases of Legionella pneumophila Pneumonia

It is not known whether rainfall increases the risk of sporadic cases of Legionella pneumonia. We sought to test this hypothesis in a prospective observational cohort study of non-immunosuppressed adults hospitalized for community-acquired pneumonia (1995-2011). Cases with Legionella pneumonia were compared with those with non-Legionella pneumonia. Using daily rainfall data obtained from the regional meteorological service we examined patterns of rainfall over the days prior to admission in each study group. Of 4168 patients, 231 (5.5%) had Legionella pneumonia. The diagnosis was based on one or more of the following: sputum (41 cases), antigenuria (206) and serology (98). Daily rainfall average was 0.556 liters/m2 in the Legionella pneumonia group vs. 0.328 liters/m2 for non-Legionella pneumonia cases (p = 0.04). A ROC curve was plotted to compare the incidence of Legionella pneumonia and the weighted median rainfall. The cut-off point was 0.42 (AUC 0.54). Patients who were admitted to hospital with a prior weighted median rainfall higher than 0.42 were more likely to have Legionella pneumonia (OR 1.35; 95% CI 1.02-1.78; p = .03). Spearman Rho correlations revealed a relationship between Legionella pneumonia and rainfall average during each two-week reporting period (0.14; p = 0.003). No relationship was found between rainfall average and non-Legionella pneumonia cases (−0.06; p = 0.24). As a conclusion, rainfall is a significant risk factor for sporadic Legionella pneumonia. Physicians should carefully consider Legionella pneumonia when selecting diagnostic tests and antimicrobial therapy for patients presenting with CAP after periods of rainfall

Effect of corticosteroids on the clinical course of community-acquired pneumonia: a randomized controlled trial

Introduction The benefit of corticosteroids as adjunctive treatment in patients with severe community-acquired pneumonia (CAP) requiring hospital admission remains unclear. This study aimed to evaluate the impact of corticosteroid treatment on outcomes in patients with CAP. Methods This was a prospective, double-blind and randomized study. All patients received treatment with ceftriaxone plus levofloxacin and methyl-prednisolone (MPDN) administered randomly and blindly as an initial bolus, followed by a tapering regimen, or placebo. Results Of the 56 patients included in the study, 28 (50%) were treated with concomitant corticosteroids. Patients included in the MPDN group show a more favourable evolution of the pO2/FiO2 ratio and faster decrease of fever, as well as greater radiological improvement at seven days. The time to resolution of morbidity was also significantly shorter in this group. Six patients met the criteria for mechanical ventilation (MV): five in the placebo group (22.7%) and one in the MPDN group (4.3%). The duration of MV was 13 days (interquartile range 7 to 26 days) for the placebo group and three days for the only case in the MPDN group. The differences did not reach statistical significance. Interleukin (IL)-6 and C-reactive protein (CRP) showed a significantly quicker decrease after 24 h of treatment among patients treated with MPDN. No differences in mortality were found among groups. Conclusions MPDN treatment, in combination with antibiotics, improves respiratory failure and accelerates the timing of clinical resolution of severe CAP needing hospital admission

Effect of corticosteroids on the clinical course of community-acquired pneumonia: a randomized controlled trial

Introduction The benefit of corticosteroids as adjunctive treatment in patients with severe community-acquired pneumonia (CAP) requiring hospital admission remains unclear. This study aimed to evaluate the impact of corticosteroid treatment on outcomes in patients with CAP. Methods This was a prospective, double-blind and randomized study. All patients received treatment with ceftriaxone plus levofloxacin and methyl-prednisolone (MPDN) administered randomly and blindly as an initial bolus, followed by a tapering regimen, or placebo. Results Of the 56 patients included in the study, 28 (50%) were treated with concomitant corticosteroids. Patients included in the MPDN group show a more favourable evolution of the pO2/FiO2 ratio and faster decrease of fever, as well as greater radiological improvement at seven days. The time to resolution of morbidity was also significantly shorter in this group. Six patients met the criteria for mechanical ventilation (MV): five in the placebo group (22.7%) and one in the MPDN group (4.3%). The duration of MV was 13 days (interquartile range 7 to 26 days) for the placebo group and three days for the only case in the MPDN group. The differences did not reach statistical significance. Interleukin (IL)-6 and C-reactive protein (CRP) showed a significantly quicker decrease after 24 h of treatment among patients treated with MPDN. No differences in mortality were found among groups. Conclusions MPDN treatment, in combination with antibiotics, improves respiratory failure and accelerates the timing of clinical resolution of severe CAP needing hospital admission