Iniciative global de prevalencia, factores de riesgo y manejo para Staphylococcus aureus resistente a la meticilina, en pacientes hospitalizados con neumonía de la comunidad

Staphylococcus aureus meticilino resistente (SAMR) se considera un problema global en crecimiento como causa de infecciones hospitalarias y recientemente en la neumonía adquirida en la comunidad (NAC). Sin embargo no se conoce el riesgo real, ni la prevalencia de esta entidad a nivel global. El objetivo de esta tesis doctoral fue evaluar la prevalencia, factores de riesgo y tratamiento empírico contra SAMR en pacientes hospitalizados por NAC. Para ello se realizó un estudio internacional multicéntrico, epidemiológico, transversal, observacional de prevalencia puntual en pacientes adultos con NAC hospitalizada en el que se obtuvieron cultivos microbiológicos durante las primeras 24 horas de ingreso. Más de 3.000 pacientes fueron reclutados en 222 centros representantes de 54 países y seis continentes en los que se obtuvieron pruebas microbiológicas de diagnóstico. La prevalencia de NAC por SAMR fue muy baja (3,0%) y solo infección o colonización previa por SAMR, infecciones recurrentes de piel y enfermedad grave por NAC fueron los factores de riesgo independientemente vinculados con NAC por SAMR. La terapia empírica contra el SAMR fue utilizada principalmente en EE.UU a pesar de la baja tasa de prevalencia. Se concluye que la sospecha clínica de NAC por SAMR requiere ponerse en contexto y considerar la prevalencia de la enfermedad en una población determinada, antes de decidir la terapia empírica con base únicamente en los factores de riesgo de SAMR.Methicillin resistant Staphylococcus aureus (MRSA) es a growing problem around the world as cause of hospital acquired infections and recently linked to community acquired pneumonia (CAP). However, the real impact at a global level is unknown, with limited data regarding the prevalence of CAP due to MRSA. The objetive of this doctoral thesis was to evaluate the prevalence, risk factors and empiric treatment for hospitalized patientes with CAP. An international, multicentric, epidemiological, point prevalence study evaluated hospitalized patients with CAP with microbiological testing within 24 hours of hospital admission. This study recruited more than 3000 patients from 222 participanting centers from 54 countries and six continents. The prevalence of CAP due to MRSA was very low (3%) and only three variables were independently associated with MRSA-CAP: prior MRSA infection or colonization, recurrent skin infection and severe CAP. The empiric MRSA treatment occurred mainly in USA, despite the low level of prevalence. The conclusion of this study suggest that a clinical suspicion for MRSA CAP requires to be place in context, the prevalence of MRSA in the population where the patient belongs and the risk factors before deciding the use of empiric therapy against MRSA

The impact of empiric antimicrobial therapy with a β-lactam and fluoroquinolone on mortality for patients hospitalized with severe pneumonia

INTRODUCTION: National clinical practice guidelines have recommended specific empiric antimicrobial regimes for patients with severe community-acquired pneumonia. However, evidence confirming improved mortality with many of these regimes is lacking. Our aim was to determine the association between the empiric use of a β-lactam with fluoroquinolone, compared with other recommended antimicrobial therapies, and mortality in patients hospitalized with severe community-acquired pneumonia. METHODS: A retrospective observational study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of community-acquired pneumonia and had a chest X-ray and a discharge ICD-9 diagnosis consistent with this. Subjects were excluded if they received 'comfort measures only' during the admission, had been transferred from another acute care hospital, did not meet criteria for severe pneumonia, or were treated with non-guideline-concordant antibiotics. A multivariable logistic regression model was used to assess the association between 30-day mortality and the use of a β-lactam antibiotic with a fluoroquinolone compared with other guideline-concordant therapies, after adjustment for potential confounders including a propensity score. RESULTS: Data were abstracted on 172 subjects at the two hospitals. The mean age was 63.5 years (SD 15.0). The population was 88% male; 91% were admitted through the emergency department and 62% were admitted to the intensive care unit within the first 24 hours after admission. Mortality was 19.8% at 30 days. After adjustment for potential confounders the use of a β-lactam with a fluoroquinolone (odds ratio 2.71, 95% confidence interval 1.2 to 6.1) was associated with increased mortality. CONCLUSION: The use of initial empiric antimicrobial therapy with a β-lactam and a fluoroquinolone was associated with increased short-term mortality for patients with severe pneumonia in comparison with other guideline-concordant antimicrobial regimes. Further research is needed to determine the range of appropriate empiric antimicrobial therapies for patients with severe community-acquired pneumonia

La reacción de inmunofluorescencia indirecta en el diagnóstico de la leishmaniasis tegumentaria americana

This paper refers to the study of 380 patients showing dermal or mucous lesions clinically compatible with leishmaniasis. The  following examinations were perfomed to all cases: direct stained smears, cultures in NNN medium, biopsy. Montenegro skin test and indirect immunofluorescence (I.I.F.). The main objetive of the study was to evaluate the I.I.F. test in the different forms of the disease and to determine its value as a diagnostic method. The test was used in 50 patients with malaria and in 50 normal individuals. Positive results were obtained in 98.7% of the patients that had positive findings for Leishmania parasites, which means a high sensitivity. In 37.4% the test was positive, when parasites were not visualized, a finding interpreted as diagnostic. In 21% of the cases the negative results discarded the diagnosis. No cross reactions were observed when the titers were 1:16 or higher. The specificity was 97.2% The antibody titers did not show any significant variations in relation to the time of evolution of the lesions, its number and the tissue invasiveness. It can be concluded that the I.I.F test is a great diagnostic aid in American mucocutaneous leishmaniasis, for which it is the orly way to make the diagnoses in a considerable number of cases. It is suggested that similar studies should be performed in endemic areas for other parasitic infections, such as Chagas disease.Se estudiaron 380 pacientes con lesiones sospechosas de leishmaniasis. A cada uno de ellos se les practicaron exámenes directos coloreados, cultivos en medio NNN, biopsia, prueba de Montenegro e inmunofluorescencia indirecta (I.F.I.). Esta última prueba fue el objeto del estudio, evaluándola en diferentes formas de la enfermedad y determinando su valor como método de diagnóstico. También se probá en 50 pacientes con malaria y 50 individuos clínicamente sanos. La I.F.I. fue positiva en el 98.7% de los pacientes en los que se demostraron también los parasitos, indicando un alto grado de sensibilidad. Además, hizo el diagnóstico por sí sola en un 37.4% de pacientes en quienes fue imposible ver el parásito. La prueba descartó la enfermedad en otro 21%. La especificidad fue del 972%. No se presentaron reacciones cruzadas de importancia cuando los títulos eran de 1:16 o mayores. Los títulos de anticuerpos I.F.I. no tuvieron variaciones significativas con el tiempo de evolución de las lesiones, su número o compromiso tisular. El valor predictivo positivo de la reacción fue de 97,2%. Se concluye que la prueba I.F.I. propuesta, es de gran ayuda en el diagnóstico de la leishmaniasis tegumentaria americana, siendo para muchos de los pacientes, el único método que confirma la infección. Es importante ampliar los estudios en otros pacientes procedentes de zonas endémicas para otras parasitosis diferentes a malaria, como la enfermedad de Chagas

HLA e malária em quatro diferentes grupos étnicos da Colômbia

HLA antigens and their relationship with malaria infection were studied in four different ethnic groups in Colombia (South America): two groups of indians (Kunas and Katios), one of negroes and a group of mixed ancestry. A total of 965 persons were studied, 415 with malaria and 550 as controls. HLA-A,B, and C antigen frequencies in the four groups are reported. The association of each HLA antigen with malaria infection due to P. vivax and to P. falciparum was evaluated. Negroes, Kunas and Katios indians variously lack from 6 to 9 of the HLA antigens found in the mixed group. In the designated ethnic groups, antigens B5, B13, B15, Cw2 and Cw4 showed borderline association with malaria infection. However, in the mixed ethnic group, statistically significant associations were found with malaria infection and the presence of A9, Aw19, B17, B35, and Z98 (a B21-B45: crossreacting determinant) with few differences when P. vivax infection and P. falciparum infection were considered individually. This finding may represent a lack of general resistance to malaria in the group that harbors antigens of Caucasian origin. These individuals have been in direct and permanent contact with malaria only in the past 65 years. In contrast, indians, both Kunas and Katios, and Negroes have lived for centuries in malaria endemic areas, and it is possible that a natural selection system has developed through which only those individuals able to initiate an acute immune response to malaria have survived.Foram estudados os antigenos HLA e a relação destes com a infecção malárica em 4 diferentes grupos étnicos da Colômbia (América do Sul); dois grupos de índios (Kunas e Katios), um grupo de negros e um grupo que apresentava ancestrais mistos. Foram estudadas 965 pessoas, das quais 415 com malária e 550 como controles. A freqüência dos antígenos HLA-A, B e C foram determinados nos quatro grupos estudados. A associação de cada antígeno HLA com a infecção por P. vivax e P. falciparum foi avaliada. Os antígenos HLA 6-9 encontrados no grupo de ancestrais mistos, de um modo geral não foram observados nos grupos de negros e índios (Kunas e Katios). Nos grupos étnicos mencionados, os antigenos B5, B13, B15, Cw2 e Cw4 apresentaram uma associação limítrofe com a infecção por malária. Entretanto, no grupo étnico de ancestrais mistos foi observada uma associação estatisticamente significativa com a infecção malárica, sendo que a presença de A9, Aw19, B17, B35 e Z98 (B21-B45: determinantes de reação cruzada) mostrou poucas diferenças quando as infecções por P. vivax e P. falciparum foram consideradas individualmente. Esse achado pode representar, de um modo geral, uma falta de resistência a malária no grupo portador de antigenos de origem caucasiana, os quais tem tido um contacto direto e permanente com a malária somente nos últimos 65 anos. Em contraste, os índios (Kunas e Katios) e os negros tem vivido durante séculos em áreas endêmicas para malária, é possível que um sistema de seleção natural tenha sido desenvolvido permitindo que somente aqueles indivíduos capazes de iniciar uma resposta imune à malária sobrevivam

Diagnóstico de leptospirosis de muestras de sangre y cultivo por observación en microscopio de campo oscuro

Leptospirosis, one of the most extended zoonosis in the world is considered a reemergent disease. It is produced by the pathogenic species of the genus Leptospira. There are approximately 13 of 17 species described up to date. These species are indistinguishable morphologically and their taxonomic classification is done by molecular methods. Leptospirosis presents with multiple unspecific clinical symptoms that make it difficult to confirm the case. To verify the diagnoses, the medical personnel need to know how to recognize the clinical manifestations for leptospirosis and to corroborate a good diagnostic suspicion, in addition to ordering the appropriate tests to the laboratory for: 1) dark field microscopy visualization of the bacteria in blood samples, urine or postmortem tissues which need to use special stains like silver stain or immunofluorescence; 2) having positive culture for leptospirosis from blood, urine, CSF or of tissues postmortem; 3) having an increase (fourfold rise) of the tires in microagglutination test from two serum samples taken with an interval of 15 days apart, 4) an elevated unique title (>1:400) using microagglutination for serological diagnosis or IgM detection test, and 5) positive PCR assay in blood, urine, CSF or tissues postmortem. Due to the fact that the first two tests for diagnosis needs a trained personnel for Leptospiras visualization, we would like to present to the medical community reference images of Leptospira species that can be observed by dark field microscopy from as blood as cultures. It is necessary to have methods for leptospirosis in the public health laboratories; additionally, to have qualified personnel to realize them. This will allow confirming a clinical diagnosis with symptoms that resemble other endemic diseases in Colombia, like dengue and malaria.La leptospirosis, una de las zoonosis más extendidas en el mundo, es considerada una enfermedad reemergente, producida por especies patógenas del género Leptospira que comprende, aproximadamente, 13 de las 17 especies descritas hasta el momento; éstas son indistinguibles morfológicamente y su clasificación taxonómica se hace por métodos moleculares. La leptospirosis se presenta con múltiples síntomas inespecíficos y para llegar a la definición de caso confirmado, el personal médico debe, además de reconocer las manifestaciones clínicas que coinciden con leptospirosis, confirmar la sospecha diagnóstica de la enfermedad por laboratorio, bien sea por: 1) observación al microscopio de campo oscuro de la bacteria en muestras de sangre u orina, o en tejidos obtenidos post mórtem y, en este caso, se usan coloraciones especiales de plata o inmunofluorescencia; 2) cultivo positivo (sangre, orina, líquido cefalorraquídeo o muestras post mórtem); 3) incremento o alza cuádruple de los títulos por microaglutinación en sueros pareados tomados con un intervalo de 15 días; 4) título alto único (>1:400) utilizando diagnóstico serológico por microaglutinación o pruebas que detecten IgM, o 5) resultado positivo de la prueba de reacción en cadena de la polimerasa en sangre, orina, líquido cefalorraquídeo o muestras de tejidos post mórtem. Debido a que las dos primeras formas de diagnóstico requieren de un personal experto para la visualización de Leptospira spp., nos proponemos presentar a la comunidad médica imágenes de referencia de Leptospira spp. que se observan en el microscopio de campo oscuro provenientes de muestras de sangre o de cultivo. Se necesita disponer de métodos de diagnóstico para leptospirosis en los laboratorios de salud pública, además de personal capacitado para realizarlos, lo cual permite confirmar el diagnóstico clínico de una etiología que como ésta, presenta síntomas comunes a otras enfermedades endémicas en Colombia, como son el dengue y el paludismo

Penetrating cardiac trauma: Analysis of 240 cases from a hospital in Bogota, Colombia

Background: Trauma characteristics and its management is influenced by socioeconomic context. Cardiac trauma constitutes a challenge for surgeons, and outcomes depend on multiple factors including initial care, characteristics of the wounds, and surgical management. Methods: This is a retrospective cross-sectional case series of patients with penetrating cardiac injuries (PCI) from January 1999 to October 2009 who underwent surgery in a trauma referral center in Bogotá, Colombia. Demographic variables, trauma characteristics, treatment, and outcomes were analyzed. Results: The study included 240 cases: 96.2% males, mean age of 27.8 years. Overall mortality was 14.6%: 11.7% from stab wounds and 41.2% from gunshot wounds. Upon admission, 44% had a normal hemodynamic status and 67% had cardiac tamponade. About 32% had Grade II injuries and 29% Grade IV injuries. In 85% of the cases, there were ventricular compromise and 55% of patients had associated lesions. In 150 cases, a pericardial window was performed. Highest mortality occurred in wounds to the right atrium. In tamponade patients, mortality was 20% being higher for gunshot wounds (54.5%) than for stab wounds (18%) (p = 0.0120). Conclusions: The study evidenced predominance of stab wounds. Based on characteristics of the trauma, patients, and survival rate, there is most likely a high pre-hospitalization mortality rate. The difference in mortality due to stab wounds and those produced by gunshots was more related to technical difficulties of the surgical repair than with the type of injury established by the Injury Grading Scale. Mortality was higher in patients with cardiac tamponade. Surgical management was satisfactory using pericardial window as the diagnostic method and sternotomy as the surgical approach. © 2017 The Author(s).Background: Trauma characteristics and its management is influenced by socioeconomic context. Cardiac trauma constitutes a challenge for surgeons, and outcomes depend on multiple factors including initial care, characteristics of the wounds, and surgical management. Methods: This is a retrospective cross-sectional case series of patients with penetrating cardiac injuries (PCI) from January 1999 to October 2009 who underwent surgery in a trauma referral center in Bogotá, Colombia. Demographic variables, trauma characteristics, treatment, and outcomes were analyzed. Results: The study included 240 cases: 96.2% males, mean age of 27.8 years. Overall mortality was 14.6%: 11.7% from stab wounds and 41.2% from gunshot wounds. Upon admission, 44% had a normal hemodynamic status and 67% had cardiac tamponade. About 32% had Grade II injuries and 29% Grade IV injuries. In 85% of the cases, there were ventricular compromise and 55% of patients had associated lesions. In 150 cases, a pericardial window was performed. Highest mortality occurred in wounds to the right atrium. In tamponade patients, mortality was 20% being higher for gunshot wounds (54.5%) than for stab wounds (18%) (p = 0.0120). Conclusions: The study evidenced predominance of stab wounds. Based on characteristics of the trauma, patients, and survival rate, there is most likely a high pre-hospitalization mortality rate. The difference in mortality due to stab wounds and those produced by gunshots was more related to technical difficulties of the surgical repair than with the type of injury established by the Injury Grading Scale. Mortality was higher in patients with cardiac tamponade. Surgical management was satisfactory using pericardial window as the diagnostic method and sternotomy as the surgical approach. © 2017 The Author(s)

Experiencia educativa con el periodismo escrito en la escuela de comunicación popular de la Corporación Educativa y Cultural Simón Bolívar de Medellín

RESUMEN: La experiencia educativa del Periodismo Escrito en la Escuela de Comunicación Popular de la Corporación Educativa y Cultural Simón Bolívar, de Medellín,se desarrolló entre los años 2009 y 2011, desde el enfoque de la investigación cualitativa con el objetivo de reconocer la experiencia educativa del Periodismo Escrito en la Escuela de Comunicación Popular de la Corporación Educativa y Cultural Simón Bolívar, de Medellín, realizada entre los años 2001 y 2011, como práctica vigente de la Educación Popular en contextos no escolarizados. La Escuela de Comunicación Popular de la Corporación Educativa y Cultural Simón Bolívar, en ese sentido, ofrece un espacio educativo abierto, donde la comunicación y el periodismo sirven de análisis y reflexión para valorar las experiencias propias de la comunidad. La enseñanza del Periodismo Escrito, Alternativo y Popular logró explorar el territorio, la conciencia ciudadana, la acción transformadora comunitaria y el trabajo colectivo. La Escuela, de esta manera, se convierte en un proyecto de vida. Transforma las percepciones sociales de los estudiantes y docentes. Aporta a que sean críticos y reflexivos. La Escuela es uno de esos escenarios, donde es posible todavía soñar que hay luz al final del túnel

Control de la enfermedad de Chagas en bancos de sangre de Colombia

The screening programs for the Chagas disease agent, Trypanosoma cruzi, were examined in Colombian blood banks and, as a consequence, several procedural improvements in the blood bank network were recommended. Screening strategies and techniques were examined, as well as the action taken when seropositive donors were discovered. From a total of 180 blood banks in 33 departments, 103 banks in 20 departments answered the survey. The 103 banks collected 291,105 units of blood, corresponding to 66.6% of all units collected in the country in 1997. Of these blood units, 99.6% were screened for Chagas trypanosomes; 3,321 (1.2%) of 287,048 were found positive for anti-T. cruzi. The data were grouped by department; geographical differences for seroprevalence rates varied markedly between 0% and 12.6%. The most commonly used serological technique was ELISA, but only 33.2% of the positive samples for anti-T. cruzi underwent further confirmatory testing, mainly through indirect immunofluorescent test. Most (95.1%) of the blood banks used basic, internal quality control procedures, and 73.8% sent positive samples to other laboratories for external quality control.Los objetivos del estudio fueron el análisis de la cobertura del programa de tamizaje para Trypanosoma cruzi en bancos de sangre de Colombia, sus estrategias en cuanto a las técnicas utilizadas, las acciones con los donantes positivos y dar algunas recomendaciones para mejorar esta red. De los 180 bancos de sangre de 33 departamentos del país, respondieron la encuesta 103, pertenecientes a 20 departamentos, que recolectaron 291.105 unidades de sangre, lo cual corresponde al 66,6% del total captado en el país en 1997. Los 103 bancos tuvieron un cumplimiento del tamizaje del 99,6%. Se informaron como positivas para anticuerpos anti- Trypanosoma cruzi 3.321 unidades de sangre de las 287.048 estudiadas, lo cual corresponde al 1,16%. Los datos se discriminaron para cada uno de los departamentos que contestaron la encuesta, observándose marcadas diferencias geográficas entre las tasas de seroprevalencia, las cuales variaban entre el 0% y el 12,6%. La técnica serológica más utilizada para el tamizaje fue la prueba de ELISA, pero solamente 33,2% de las muestras positivas para anticuerpos se sometieron a una prueba confirmatoria, la gran mayoría a la de inmunofluorescencia indirecta. El 95,1% de los bancos respondieron que utilizaban controles de calidad internos básicos de las pruebas y el 73,8% remitían pruebas positivas a otro laboratorio para control de calidad externo