Mejora en el manejo de las cistitis en atención primaria después de la implementación de una intervención multimodal simple

Primary health care; Urinary tract infections; Urine cultureAtención primaria; Infecciones del tracto urinario; UrocultivoAtenció primària; Infeccions del tracte urinari; UrocultiuObjective We assessed the impact of the implementation of a simple multifaceted intervention aimed at improving management of cystitis in primary care. Design Quality control before and after study. Site Primary care centres in Barcelona city provided by the Catalonian Institute of Health. Participants The multifaceted intervention consisted of (1) creation of a group with a leader in each of the primary care centres, out of hours services, sexual and reproductive centres, and home visit service, (2) session on management of cystitis in each centre, (3) result feedback for professionals, and (4) provision of infographics for professionals and patients with urinary tract infections. Interventions started in November 2020 and ended in the summer of 2021. Main measurements Variation in the prescription of first-line antibiotics, usage of antibiotics, and request for urine cultures before and after this intervention. Results Training sessions took place in 93% of the centres. The use of first-line therapies cystitis increased by 6.4% after the intervention (95% confidence interval [CI], 5.7–7.1%). The use of nitrofurantoin in recurrent cystitis increased, mainly in out of hours service (8.7%; 95% CI, 5.2–12.2%). Urine cultures were more frequently requested after the intervention for recurrent cystitis in both primary care centres and out of hours services, with a 7.2% increase [95% CI, 5.9–8.5%), but also for uncomplicated urinary tract infections (3.1%; 95% CI, 1.8–4.4%). Conclusions A low-intensity multifaceted intervention on management of cystitis, with strong institutional support, resulted in a better choice of antibiotic in antibiotic prescribing, but the intervention had less impact on the adequacy of urine cultures.Objetivo Evaluamos el impacto de una intervención multimodal en la mejora del manejo de las cistitis en atención primaria. Diseño Estudio de calidad antes-después. Emplazamiento Centros de atención primaria de la ciudad de Barcelona proporcionados por el Institut Català de la Salut. Participantes La intervención multimodal consistió en: (1) creación de un grupo de trabajo con líderes en cada uno de los equipos de atención primaria, servicios de urgencias, centros de atención sexual y reproductiva y servicio de atención domiciliaria, (2) sesión formativa sobre el manejo de las infecciones del tracto urinario en cada centro, (3) retorno de resultados a profesionales, y (4) difusión de infografías a profesionales y pacientes. Las intervenciones comenzaron en noviembre de 2020 y finalizaron en verano de 2021. Mediciones principales Variación en la prescripción de antibióticos de primera línea, uso de antibióticos y solicitud de urocultivos antes y después de esta intervención. Resultados Las sesiones de formación se realizaron en el 93% de los centros. La selección de fármacos de primera línea en cistitis aumentó en un 6,4% después de la intervención (intervalo de confianza [IC] 95%: 5,7-7,1%). El uso de nitrofurantoína en cistitis recurrente aumentó, principalmente en servicios de urgencias (8,7%; IC 95%: 5,2-12,2%). Las solicitudes de urocultivos aumentaron después de la intervención en equipos de atención primaria y servicios de urgencias en cistitis recurrentes (7,2%; IC 95%: 5,9-8,5%), pero también en cistitis simples (3,1%; IC 95%: 1,8-4,4%). Conclusiones Una intervención multimodal de baja intensidad sobre el manejo de las cistitis junto con el apoyo institucional explícito mejoró claramente la selección de antibióticos, pero tuvo menos impacto en la adecuación de los urocultivos

Rapid detection and identification of strains carrying carbapenemases directly from positive blood cultures using MALDI-TOF MS

MALDI-TOF MS has been evaluated to detect carbapenemases activity and pathogen identification directly from positive blood cultures. 21 non-carbapenemase producers and 19 carbapenemase producers Enterobacteriaceae and Pseudomonas aeruginosa strains were included in the study. This technique is simple and detects carbapenemases in 4.5h with high sensitivity and specificity

Oral fosfomycin for treatment of acute bacterial prostatitis caused by multidrug-resistant Enterobacterales

Acute prostatitis; Fosfomycin-tromethamine; Multidrug resistanceProstatitis aguda; Fosfomicina-trometamina; Resistència a múltiples medicamentsProstatitis aguda; Fosfomicina-trometamina; Resistencia a múltiples medicamentosTo assess the feasibility of oral fosfomycin-tromethamine (FT) for the management of acute bacterial prostatitis (ABP) caused by multidrug-resistant (MDR) Enterobacterales. An observational study of adult patients diagnosed with ABP from Vall d’Hebron University Hospital (Barcelona, Spain), treated with oral FT. The primary outcome was clinical cure defined as symptom relief at the control visit, 2–4 weeks post-end of treatment. Secondary outcomes included microbiological cure, relapse, and adverse events related to the treatment. Eighteen patients with ABP caused by Enterobacterales (15 Escherichia coli and three Klebsiella pneumoniae) were included. Microorganisms were MDR bacteria [14 extended-spectrum beta-lactamase (ESBL) producers and two carbapenemase producing K. pneumoniae]. Patients received treatment with FT 3 g/48 hours during a median of 14 days (Q25–Q75, 12–17.75). Fifteen patients received a lead-in phase of intravenous suitable antimicrobial during a median of 7 days (Q25–Q75, 3.75–8). No patient had to stop treatment due to adverse events, and the only side effect reported in two patients was diarrhea. Clinical cure was achieved in all (18/18) patients and microbiological cure in 11/12 patients. After a median of follow-up of 5 months (Q25–Q75, 2–11), 2/18 patients relapsed with an orchitis and a new episode of ABP. FT is an attractive step-down therapy for ABP in patients with resistance or side effects to first-line drugs. The availability of oral treatment could reduce the use of the carbapenems, with a benefit in the quality of life of the patient, health costs, and an ecological impact

High increase of Nichols-like clade circulating Treponema pallidum subsp. pallidum in Barcelona from 2021 to 2023

Treponema pallidum; Phylogeny; SyphilisTreponema pallidum; Filogenia; SífilisTreponema pallidum; Filogènia; SífilisWorldwide, more than 90% of contemporary syphilis strains belong to SS14-like clade. This study aimed to describe the molecular profile of circulating Treponema pallidum subsp. pallidum (TPA) strains in Barcelona, Spain, from 2021 to 2023 building upon our report in 2015 which showed that 94.8% of typed strains belonged to the SS14 clade. Multilocus sequence typing (MLST) was conducted on TPA-positive samples obtained from swab samples by sequencing the tp0136, tp0548, and tp0705 loci. Strains were classified as Nichols-like or SS14-like clade. Macrolide and tetracycline resistance‑associated mutations were determined through analysis of 23S rDNA and 16S rRNA gene sequences. Of the 96 typeable samples, 47.9% belonged to SS14-like and 52.1% to the Nichols-like. Fourteen haplotypes were identified, with ST26 representing 43.8% of the samples, distributed across 11 haplotypes in the SS14-like and 3 haplotypes in the Nichols-like. All the samples showed macrolide resistance-associated mutations, while none exhibited tetracycline-associated mutations. Our findings revealed a substantial shift in the proportion of TPA clades within the Barcelona population from 2021 to 2023, characterized by a higher proportion of Nichols-like strains compared to 2015 and international trends. The varying temporal and geographical trends underscore the need for regular surveillance to understand regional variations in syphilis and strengthen control programs

Oral linezolid compared with benzathine penicillin G for treatment of early syphilis in adults (Trep-AB Study) in Spain : a prospective, open-label, non-inferiority, randomised controlled trial

Background: Management of syphilis, a sexually transmitted infection (STI) with increasing incidence, is challenged by drug shortages, scarcity of randomised trial data, an absence of non-penicillin alternatives for pregnant women with penicillin allergy (other than desensitisation), extended parenteral administration for neurosyphilis and congenital syphilis, and macrolide resistance. Linezolid was shown to be active against Treponema pallidum, the causative agent of syphilis, in vitro and in the rabbit model. We aimed to assess the efficacy of linezolid for treating early syphilis in adults compared with the standard of care benzathine penicillin G (BPG). Methods: We did a multicentre, open-label, non-inferiority, randomised controlled trial to assess the efficacy of linezolid for treating early syphilis compared with BPG. We recruited participants with serological or molecular confirmation of syphilis (either primary, secondary, or early latent) at one STI unit in a public hospital and two STI community clinics in Catalonia (Spain). Participants were randomly allocated in a 1:1 ratio using a computer-generated block randomisation list with six participants per block, to receive either oral linezolid (600 mg once per day for 5 days) or intramuscular BPG (single dose of 2·4 million international units) and were assessed for signs and symptoms (once per week until week 6 and at week 12, week 24, and week 48) and reagin titres of non-treponemal antibodies (week 12, week 24, and week 48). The primary endpoint was treatment response, assessed using a composite endpoint that included clinical response, serological response, and absence of relapse. Clinical response was assessed at 2 weeks for primary syphilis and at 6 weeks for secondary syphilis following treatment initiation. Serological cure was defined as a four-fold decline in rapid plasma reagin titre or seroreversion at any of the 12-week, 24-week, or 48-week timepoints. The absence of relapse was defined as the presence of different molecular sequence types of T pallidum in recurrent syphilis. Non-inferiority was shown if the lower limit of the two-sided 95% CI for the difference in rates of treatment response was higher than -10%. The primary analysis was done in the per-protocol population. The trial is registered at ClinicalTrials.gov (NCT05069974) and was stopped for futility after interim analysis. Findings: Between Oct 20, 2021, and Sept 15, 2022, 62 patients were assessed for eligibility, and 59 were randomly assigned to linezolid (n=29) or BPG (n=30). In the per-protocol population, after 48 weeks' follow-up, 19 (70%) of 27 participants (95% CI 49·8 to 86·2) in the linezolid group had responded to treatment and 28 (100%) of 28 participants (87·7 to 100·0) in the BPG group (treatment difference -29·6, 95% CI -50·5 to -8·8), which did not meet the non-inferiority criterion. The number of drug-related adverse events (all mild or moderate) was similar in both treatment groups (five [17%] of 29, 95% CI 5·8 to 35·8 in the linezolid group vs five [17%] of 30, 5·6 to 34·7, in the BPG group). No serious adverse events were reported during follow-up. Interpretation: The efficacy of linezolid at a daily dose of 600 mg for 5 days did not meet the non-inferiority criteria compared with BPG and, as a result, this treatment regimen should not be used to treat patients with early syphilis. Funding: European Research Council and Fondo de Investigaciones Sanitarias

Aplicación de la tecnología MALDI-TOF MS para la detección de carbapenemasas

Tesis Univ. Granada. Programa Oficial de Doctorado en: Medicina Clínica y Salud PÚblic

OXA-244-Producing Escherichia coli Isolates, a Challenge for Clinical Microbiology Laboratories

International audienceOXA-244 is a single-point-mutant derivative of OXA-48 displaying reduced carbapenemase activity. Here, we report the microbiological features of seven OXA-244-producing Escherichia coli isolates. Only one isolate grew on ChromID Carba Smart medium (bioMérieux), but six of the seven isolates grew on ChromID extended-spectrum-β-lactamase (ESBL) medium (bioMérieux), as they coproduced an ESBL and/or a plasmid-encoded cephalosporinase. The production of a carbapenemase was detected in 57.1%, 71.4%, 71.4%, and 100% of the E. coli isolates using the Carba NP test, the Rapidec Carba NP test (bioMérieux), a matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) hydrolysis assay (Bruker), and the OXA-48 K-SeT assay (Coris BioConcept), respectively. Our results indicate that OXA-244-producing E. coli isolates are difficult to detect, which may lead to their silent spread

New paradigms on antibiotic recommendations for community-acquired infections in Spain

Over the last years, the susceptibility activity of the most common microorganisms causing community-acquired infections has significantly changed in Spain. Based on the susceptibility rates of Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, and Klebsiella pneumoniae collected from outpatients aged 15 or older with symptoms of respiratory or urinary tract infections in several Microbiology Departments in Catalonia in 2021, penicillin V should be first choice for most respiratory tract infections, amoxicillin and clavulanate for chronic obstructive pulmonary disease exacerbations and a single dose of fosfomycin or a short-course nitrofurantoin should remain first-line treatments for uncomplicated urinary tract infections. Updated information on antimicrobial resistance for general practitioners is crucial for achieving appropriate empirical management of the most common infections by promoting more rational antibiotic use. Resumen: En los últimos años han cambiado significativamente los porcentajes de sensibilidad de los microorganismos más comunes que causan infecciones adquiridas en la comunidad en España. A partir de los porcentajes de sensibilidad de Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli y Klebsiella pneumoniae, recogidas de aislados de pacientes ambulatorios de 15 años o más, con síntomas de infecciones respiratorias o urinarias en servicios de microbiología de Cataluña en 2021, fenoximetilpenicilina debería ser la primera opción en la mayoría de los infecciones respiratorias, amoxicilina y ácido clavulánico en las exacerbaciones de la enfermedad pulmonar obstructiva crónica y la monodosis de fosfomicina o la pauta corta de nitrofurantoína como tratamiento de primera línea en las infecciones urinarias no complicadas. Es importante que los médicos de familia dispongan de información actualizada sobre la resistencia a los antimicrobianos para lograr un manejo empírico adecuado de las infecciones más frecuentes al promover un uso más racional de los antibióticos

Diagnosis of leishmaniasis

Leishmaniasis is a clinically heterogeneous syndrome caused by intracellular protozoan parasites of the genus Leishmania. The clinical spectrum of leishmaniasis encompasses subclinical (not apparent), localized (skin lesion), and disseminated (cutaneous, mucocutaneous, and visceral) infection. This spectrum of manifestations depends on the immune status of the host, on the parasite, and on immunoinflammatory responses. Visceral leishmaniasis causes high morbidity and mortality in the developing world. Reliable laboratory methods become mandatory for accurate diagnosis, especially in immunocompromised patients such as those infected with HIV. In this article, we review the current state of the diagnostic tools for leishmaniasis, especially the serological test

Rapid test for detection of susceptibility to cefotaxime in Enterobacteriaceae

En este trabajo se evalúa una prueba rápida in house para la detección de enterobacterias sensibles a cefotaxima, basada en el cambio de pH del rojo fenol debido a la hidrólisis de este antibiótico. Las cepas de enterobacterias procedentes de 1.947 urocultivos se evaluaron mediante los paneles MicroScan y esta prueba in house. Mediante los paneles de MicroScan se estudiaron 499 aislados de enterobacterias, entre los cuales había 27 aislados de Escherichia coli productora de β-lactamasa de espectro extendido (BLEE), 16 de Klebsiella pneumoniae BLEE y una de Klebsiella oxytoca BLEE. La prueba in house mostró una sensibilidad del 98% y una especificidad del 97%, con un valor predictivo negativo del 100% y un valor predictivo positivo del 78%. La prueba in house basada en el cambio de pH es útil en nuestro medio para detectar presuntivamente de forma rápida cepas de enterobacterias con cierta resistencia a cefotaxima.In this work an “in house” rapid test based on the change in pH that is due to hydrolysis for detecting Enterobacteriaceae susceptible to cefotaxime is evaluated. The strains of Enterobacteriaceae from 1947 urine cultures were assessed using MicroScan panels and the “in house” test. This rapid test includes red phenol solution and cefotaxime. Using MicroScan panels, 499 Enterobacteriaceae isolates were evaluated, which included 27 isolates of Escherichia coli producing extended-spectrum beta-lactamases (ESBL), 16 isolates of Klebsiella pneumoniae ESBL and 1 isolate of Klebsiella oxytoca ESBL. The “in house” test offers the following values: sensitivity 98% and specificity 97%, with negative predictive value 100% and positive predictive value 78%. The “in house” test based on the change of pH is useful in our area for detecting presumptively cefotaxime-resistant Enterobacteriaceae strains