Impact of Sepsis Flow Chip, a novelty fast microbiology method, in the treatment of bacteremia caused by Gram-negative bacilli

Objective

The aim of this study was to assess the impact of the information provided by the new Sepsis Chip Flow system (SFC) and other fast microbiological techniques on the selection of the appropriate antimicrobial treatment by the clinical researchers of an antimicrobial stewardship team.

Methods

Two experienced clinical researchers performed the theoretical exercise of independently selecting the treatment for patients diagnosed by bacteremia due to bacilli gram negative (BGN). At first, the clinicians had only available the clinical characteristics of 74 real patients. Sequentially, information regarding the Gram stain, MALDI-TOF, and SFC from Vitro were provided. Initially, the researchers prescribed an antimicrobial therapy based on the clinical data, later these data were complementing with information from microbiological techniques, and the clinicians made their decisions again.

Results

The data provided by the Gram stain reduced the number of patients prescribed with combined treatments (for clinician 1, from 23 to 7, and for clinician 2, from 28 to 12), but the use of carbapenems remained constant. In line with this, the data obtained by the MALDI-TOF also decreased the combined treatment, and the use of carbapenems remained unchanged. By contrast, the data on antimicrobial resistance provided by the SFC reduced the carbapenems treatment.

Conclusions

From the theoretical model the Gram stain and the MALDI-TOF results achieved a reduction in the combined treatment. However, the new system tested (SFC), due to the resistance mechanism data provided, not only reduced the combined treatment, it also decreased the prescription of the carbapenems.

A versatile microfluidic platform measures hyphal interactions between Fusarium graminearum and Clonostachys rosea in real-time

Routinely, fungal-fungal interactions (FFI) are studied on agar surfaces. However, this format restricts high-resolution dynamic imaging. To gain experimental access to FFI at the hyphal level in real-time, we developed a microfluidic platform, a FFI device. This device utilises microchannel geometry to enhance the visibility of hyphal growth and provides control channels to allow comparisons between localised and systemic effects. We demonstrate its function by investigating the FFI between the biological control agent (BCA) Clonostachys rosea and the plant pathogen Fusarium graminearum. Microscope image analyses confirm the inhibitory effect of the necrotrophic BCA and we show that a loss of fluorescence in parasitised hyphae of GFP-tagged F. graminearum coincides with the detection of GFP in mycelium of C. rosea. The versatility of our device to operate under both water-saturated and nutrient-rich as well as dry and nutrient-deficient conditions, coupled with its spatio-temporal output, opens new opportunities to study relationships between fungi.

[How to organize a Fetal Medicine Unit in the context of COVID-19 pandemic. Safe measures for obstetric scans and equipment cleaning]

During a pandemic, the three basic principles are. to prioritize medical resources, ensure patients' lockdown in order to avoid community transmission and prevent healthcare collapse, and keep the number of visits to an absolute minimum to avoid patient exposure and safeguard healthcare workers. Antenatal care must be maintained during a health crisis, regardless of the COVID-19 state of alert. Routine and specialist obstetric ultrasound scans are essential for clinical decision-making during pregnancy, as it has a direct impact on the management of mothers and fetuses and on the perinatal outcome. In an attempt to minimize in-person visits, these will be organized according to the established ultrasound schedule. Based on scientific evidence, and on existing main national and international guidelines, this document has been prepared, in which proposals and options are provided for managing pregnant women in the context of the SARS-CoV-2 pandemic. It includes how a Fetal Medicine Unit facing this health crisis should be restructured, what safety measures should be followed in the performance of obstetric scans and invasive procedures, and how ultrasound rooms, equipment and transducers should be cleaned and disinfected. These recommendations should be adapted to different units based on their resources and infrastructure.

Overcoming multimorbidity: Chrodis Integrated Multimorbidity Care Model pilot implementation

Background

Multimorbidity (MM) has become one of the greatest challenges for patients and healthcare providers, calling for the development of care models that offer holistic, patient-centered care plans. Our objective was to assess the applicability and effectiveness of the Chrodis Integrated Multimorbidity Care Model (IMCM) to improve care for patients with MM in the Public Health System of Aragón, a region in northeastern Spain where MM affects 80% of people over 65 years of age.

Methods

We developed and implemented a set of actions (”change package”) to target three main improvement areas (i.e., care fragmentation, training of professionals and community care) covering all five dimensions of the model. We used key process and outcome indicators to evaluate each action, including healthcare service use (hospitalizations, emergency room visits), delivery of care (care plans, case managers), improvement in MM management skills of professionals (online training course), and patient self-perceived quality of care (ad-hoc questionnaire).

Results

291 patients of over 65 years of age with MM were recruited. At the end of the implementation every patient had a designated case manager and an individualized care plan, and 96.7% had their social situation assessed. During the 1-year pilot intervention, patients averaged 0.69 hospitalizations and 1.24 visits to the emergency room; 87.5% reported a self-perceived improvement of received care. 348 community resources were mapped and made available online in an official website. 89% of professionals who were offered to participate in the training programme agreed, reporting 8.3/10 satisfaction with the course, and improved their MM management skills from 7.36 to 9.18/10.

Conclusions

The IMCM is applicable in the context of the Spanish Public Health System and is effective in improving quality of care for patients and professionals alike.

Key messages

Reinforcing the mechanisms that integrate community, primary and hospital care is still necessary if we intend to reduce the negative health outcomes associated to care fragmentation in multimorbidity. The sustainability of the model requires the continued collaboration of key stakeholders and the awareness that multimorbidity is an issue that exceeds purely economic and structural barriers.

Etiology of bloodstream infections at a population level during 2013-2017 in the Autonomous Community of Valencia, Spain

Introduction

Bloodstream Infections has become in one of the priorities for the antimicrobial stewardship teams due to their high mortality and morbidity rates. Usually, the first antibiotic treatment for this pathology must be empirical, without microbiology data about the microorganism involved. For this reason, the population studies about the etiology of bacteremia are a key factor to improve the selection of the empirical treatment, because they describe the main microorganisms associated to this pathology in each area, and this data could facilitate the selection of correct antibiotic therapy.

Material and methods

This study describes the etiology of bloodstream infections in the Southeast of Spain. The etiology of bacteremia was analysed by a retrospective review of all age-ranged patients from every public hospital in the Autonomous Community of Valencia (approximately 5,000,000 inhabitants) for five years.

Results

A total of 92,097 isolates were obtained, 44.5% of them were coagulase-negative staphylococci. Enterobacteriales was the most prevalent group and an increase in frequency was observed along the time. Streptococcus spp. were the second microorganisms more frequently isolated. Next, the most prevalent were Staphylococcus aureus and Enterococcus spp., both with a stable incidence along the study. Finally, Pseudomonas aeruginosa was the fifth microorganism more frequently isolated.

Conclusions

These data constitute a useful tool that can help in the choice of empirical treatment for bloodstream infections, since the knowledge of local epidemiology is key to prescribe a fast and appropriate antibiotic therapy, aspect capital to improve survival.

From laboratory to the field: biological control of Fusarium graminearum on infected maize crop residues

Aim

To evaluate biological control agents (BCAs) against Fusarium graminearum on infected maize stalks as a means to reduce Fusarium head blight (FHB) in subsequently grown wheat.

Methods and Results

In the laboratory, BCAs were applied against F. graminearum on maize stalk pieces. Clonostachys rosea inhibited the perithecia development and ascospore discharge when applied before, simultaneously with and after the pathogen. In the field, we simulated a system with high disease pressure, that is, a maize‐wheat rotation under no‐tillage, by preparing maize stalks inoculated with F. graminearum. The infected stalks were treated with formulations of C. rosea selected in vitro or the commercial BCA strain Trichoderma atrobrunneum ITEM908 and exposed to field conditions over winter and spring between winter wheat rows. Monitoring with spore traps and of FHB symptoms, as well as quantification of F. graminearum incidence and DNA in harvested grain revealed significant reductions by C. rosea by up to 85, 91, 69 and 95% compared with an inoculated but untreated positive control, respectively. Deoxynivalenol (DON) and zearalenone (ZEN) contents were reduced by up to 93 and 98%, respectively. Treatments with T. atrobrunneum were inconsistent, with significant reductions of DON and ZEN under warm and wet climatic conditions only.

Conclusions

The findings support the application of C. rosea against F. graminearum on residues of maize to suppress the primary inoculum of FHB.

Significance and Impact of the Study

As sustainable agriculture requires solutions to control FHB, hence, the application of C. rosea during the mulching of maize crop residues should be evaluated in on‐farm experiments.

TaqMan qPCR for Quantification of Clonostachys rosea Used as a Biological Control Agent Against Fusarium graminearum

Clonostachys rosea is a biological control agent against Fusarium graminearum in small grain cereals and maize. Infections with F. graminearum do not only reduce the yield but, due to the production of mycotoxins, also affect the entire value chain of food and feed. In addition, production of other secondary metabolites such as hydrophobins, also known as gushing inducers, may cause quality challenges for the malting and brewing industry. Sustainable disease control strategies using C. rosea are treatment of infected residues of the previous crop, direct treatment of the actual cereal crop or post-harvest treatment during malting processes. Follow-up of growth and survival of biocontrol organisms during these different stages is of crucial importance. In the current study, we developed a quantitative real-time PCR detection method that amends the currently available culture-dependent techniques by using TaqMan chemistry with a highly specific primer and probe set, targeting the actin gene. We established a sensitive assay that detects the biological control agent down to 100 genome copies per reaction, with PCR efficiencies between 90 and 100%. The specificity of the assay was confirmed against a panel of 30 fungal and 3 bacterial species including 12 members of the Fusarium head blight complex and DNA of barley, maize and wheat. The DNA of C. rosea was detected in Fusarium-infected maize crop residues that were either treated in the laboratory or in the field with C. rosea and followed its DNA throughout the barley malting process to estimate its growth during grain germination. We used a standardized DNA extraction protocol and showed that C. rosea can be quantified in different sample matrices. This method will enable the monitoring of C. rosea during experiments studying the biological control of F. graminearum on cereal crop residues and on cereal grains and will thus contribute to the development of a new disease control strategy.

Abstract P6-18-17: Ribociclib + letrozole in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (aBC) with no prior endocrine therapy (ET) for ABC: CompLEEment-1 trial, preliminary results from Spanish population

Background: The phase III Monaleesa-2, Monaleesa-3 and Monaleesa-7 trials have shown significantly improved PFS for the combination ribociclib + ET vs ET + placebo in pre-, peri-, and postmenopausal women with HR+/HER2–, first and second line aBC. The Compleement-1 trial is a phase IIIb, single-arm, open-label, international study to assess the safety and efficacy of ribociclib + letrozole in men and women who have not received prior ET for HR+, HER2– ABC [J Clin Oncol 36, 2018 (suppl; abstr 1056)].

Methods: 526 patients with HR+, HER2– ABC, ≤1 line of prior CT, and no prior ET for aBC were enrolled in the Compleement-1trial in Spain from April 2017 to January 2018. Patients received ribociclib (600 mg/day, 3 weeks on/1 week off) + letrozole (2.5 mg/day); men and premenopausal women received concomitant goserelin (3.6 mg subcutaneous implant every 28 days). The primary objective was safety and tolerability. Here we report on a sub-analysis from the Spanish population of Compleement-1 trial including baseline characteristics and early safety results for the first patients enrolled who completed at least 56 days of follow-up or discontinued before the cut-off date (3rd Oct 2017).

Results: One hundred fifty four patients constituted the analytical cohort for this sub-analysis. Demographics and baseline characteristics: median age was 52 years (range 24-82); 1% of patients were male, 31.8% female pre-menopausal and 67.5% female post-menopausal; 44.2% vs 38.3% of patients had visceral disease vs bone only disease; 49.9% patients had ≥2 metastatic sites; and 34.4% of patients presented as de novo stage IV. The median exposure for study treatment was 1.8 months (range 0.8-1.8). The grade 3/4 events reported >1% included neutropenia (50%), increased GGT levels (3.2%), leukopenia (1.3%), and increased ALT (1.3%). QTcF prolongation >480ms based on ECG data was reported in 1.2% patients. Median dose intensity for ribociclib was 600mg/day (range 476.5-600); 11% of patients required one dose reduction (8.4% due to AEs), 59.7% had at least one dose interruption (57.1% due to AEs) and 9.7% were permanently discontinued (4.5% due to AEs).

Conclusions: Preliminary safety results from this Compleement-1 sub-analysis including Spanish population are consistent with previous data presented from Monaleesa-2, Monaleesa-3, Monaleesa-7 and Compleement-1. These data support the predictable and manageable safety profile of ribociclib in combination with letrozole. Clinical trial information: NCT02941926

Citation Format: Salvador J, Ciruelos EM, Prat A, Jiménez-Rodríguez B, de la Cruz L, Martínez N, Villanueva Vázquez R, de Toro R, Antón A, Moreno F, Alvarez I, Gavila J, Quiroga V, Vicente E, de la Haba J, González-Santiago S, Díaz N, Barnadas A, Cantos Sánchez de Ibargüen B, Delgado JI, Bellet M, Gimeno A, Sanz S, Martin M. Ribociclib + letrozole in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (aBC) with no prior endocrine therapy (ET) for ABC: CompLEEment-1 trial, preliminary results from Spanish population [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-17.

Effects of the citrus flavonoid extract Bioflavex or its pure components on rumen fermentation of intensively reared beef steers

Two experiments were performed to study the effects of the citrus flavonoid extract Bioflavex (BF; Interquim SA, FerrerHealthTech, Sant Cugat, Barcelona, Spain) or its components on the rumen fermentation of a high-concentrate diet. In an in vivo experiment, eight Friesian steers (398 ± 12.2 kg bodyweight) fitted with a rumen cannula were given a basal concentrate (CTR) or a CTR supplemented with BF (450 mg/kg dry matter, DM) in a 2 × 4 crossover design. No differences were observed in performance parameters of BF and CTR steers. Diet BF increased pH values and the molar proportion of propionate and reduced lactate concentration as a result of an increase in the relative abundance of lactate-consuming microorganism Selenomomas ruminantium (P < 0.01) and Megaesphaera elsdenii (P = 0.06). In an in vitro experiment, the effect of BF and its pure flavonoid components added to the incubation medium was studied separately. Bioflavex and its main components naringine, neohesperidine (NH) and poncirine (PC) were added to the incubation medium at 500 µg/g DM, with the unsupplemented substrate also included as a control (CTR). After 12 h of incubation, flavonoid mixture and NH and PC reduced (P < 0.01) the volume of gas produced and the molar proportion of acetate (P < 0.01), and increased that of propionate (P < 0.01). PC reduced the relative quantification of Streptococcus bovis, whereas NH and BF increased the relative quantification of M. elsdenii in relation to CTR (P < 0.01). Bioflavex supplementation in steers in feedlot was effective in preventing a collapse in pH and it enhanced rumen fermentation efficiency through modifying the activity of lactate-consuming bacteria and a greater molar proportion of propionate and a reduction of that of acetate, suggesting its positive role in modulating the activity of rumen microbiota.

Impact of a stewardship program on bacteraemia in adult inpatients

OBJECTIVE

Bloodstream infections (BSIs) are associated with considerable morbidity and mortality among inpatients. The aim of this study was to evaluate the impact of a stewardship program on clinical and antimicrobial therapy-related outcomes in patients with bacteraemia.

METHODS

Single-centre, before-and-after quasi-experimental study in adult inpatients. Over 1 January 2013 to 31 June 2013 all patients aged 18 years or older with a bacteraemia (interven-tion group, N=200) were compared to a historical cohort (1 Janu-ary 2012 to 31 December 2012) (control group, N=200).

RESULTS

Following blood culture results and adjusting for potential confounders, the stewardship program was associated with more changes to antibiotic regimens (adjusted odds ratio [ORa]: 4.6, 95% CI 2.9, 7.4), more adjustments to antimicrobial therapy (ORa: 2.4, 95% CI 1.5, 3.8), and better source control in the first five days (ORa 1.6, 95% CI: 1.0, 2.7). In the subgroup that initially received inappropriate empiric treatment (n=138), the intervention was associated with more antibiotic changes (OR: 3.9, 95% CI: 1.8, 8.5) and a better choice of definitive antimicrobial therapy (OR 2.3 95% CI: 1.2, 4.6). There were also more antibiotic changes in the subgroups with both Gram-negative (OR: 2.8, 95% CI: 1.6, 4.9; n=217) and Gram-positive (OR: 4.6, 95% CI: 1.8, 9.9; n=135) bacteraemia among those receiving the intervention, while the Gram-positive subgroup also received more appropriate definitive antimicrobial therapy (OR: 3.9, 95% CI: 1.8, 8.8).

CONCLUSIONS

The stewardship program improved treatment of patients with bacteraemia and appropriateness of therapy.

Single shot spinal anesthesia with very low hyperbaric bupivacaine dose (3.75 mg) for hip fracture repair surgery in the elderly. A randomized, double blinded study

PURPOSE

Single shot spinal anesthesia is used worldwide for hip fracture repair surgery in the elderly. Arterial hypotension is a frequent adverse effect. We hypothesized that lowering local anesthetics dose could decrease the incidence of arterial hypotension, while maintaining quality of surgical anesthesia.

METHODS

In a randomized double blinded study, 66 patients over the age of 65 years, with hip fracture needing surgical repair, were assigned to B0.5 group 7.5mg hyperbaric bupivacaine 5mg/ml (control group), and B0.25 group 3.75mg hyperbaric bupivacaine 2.5mg/ml (study group). Sensory and motor block level, and hemodynamic parameters including blood presure, heart rate and vasopressor dose administration were registered, along with rescue anesthesia needs, the feasibility of surgery, its duration, and regression time of sensory anesthesia to T12.

RESULTS

After exclusions, 61 patients were included in the final analysis. Arterial hypotension incidence was lower in the B0.25 group (at the 5, 10, and 15min determinations), and a lower amount of vasopressor drugs was needed (mean accumulated ephedrine dose 1.6mg vs. 8.7mg in the B0.5 group, p<0.002). Sensory block regression time to T12 was shorter in the B0.25 group, mean 78.6±23.6 (95% CI 51.7-110.2)min vs. 125.5±37.9 (95% CI 101.7-169.4)min in the B0.5 group, p=0.033. All but one patient in the B0.25 group were operated on under the anesthetic procedure first intended. No rescue anesthesia was needed.

CONCLUSION

Lowering bupivacaine dose for single shot spinal anesthesia for hip fracture repair surgery in elderly patients was effective in decreasing the occurrence of arterial hypotension and vasopressor use, while intraoperative quality remained.

Effects of including olive cake in the diet on performance and rumen function of beef cattle

Beef meat in many Mediterranean countries is produced by feeding the animals with high proportions of concentrates and barley straw. In these conditions, feeding costs are high and compromise the profitability of feedlots. Mediterranean countries are also major producers of olive oil, and the processing of this product generates a large quantity of co-products with a high environmental impact. No data appear available in the literature about the effects of including olive by-products in the diet of beef cattle on animal performance. A pen-feeding study was carried out during two growing phases: from 100 to 250 kg (12 weeks), and from 250 to 450 kg (18 weeks). During the first phase 120 steers (mostly Friesian, with an average age of 129 ± 1.1 days) were distributed in six groups of 20 animals each. Two groups were assigned to one of each of the following treatments: a control compound feed based on barley, control with 10% dry matter (DM) substituted by second-extraction pitted and dehydrated olive cake, and control with 20% DM substituted by olive cake. Compound feeds of this first phase were formulated to contain 16–17% crude protein, and were offered ad libitum to the animals. Barley straw was offered as a roughage source. Animals were weighed every 3 weeks, and a digestibility trial was carried out in the middle of the period with four animals per treatment. During the second phase, compound feeds were formulated to contain 14.5–15% crude protein. Rumen fermentation was studied using six steers and the feeds employed in the second growing phase, following a crossover design with two periods. Concentrates were offered once daily allowing at least 10% refusals. Barley straw was also offered as a source of roughage. For each period of the crossover, 15 days were allowed for adaptation to the experimental diets. Samples of rumen liquid were taken at 0 (just before), 4 and 8 h after feeding. The pH, and concentrations of ammonia and volatile fatty acids were determined. Inclusion of up to 20% second-extraction pitted and dehydrated olive cake (DM basis) in the diet did not affect performance of beef steers for the whole growth period. Inclusion of those ingredients in the diet of these animals might be advisable depending on their market price.

Remediation trials for hydrocarbon-contaminated sludge from a soil washing process: evaluation of bioremediation technologies

The usual fate of highly contaminated fine products (silt-clay fractions) from soil washing plants is disposal in a dump or thermal destruction (organic contaminants), with consequent environmental impacts. Alternative treatments for these fractions with the aim of on-site reuse are needed. Therefore, the feasibility of two technologies, slurry bioremediation and landfarming, has been studied for the treatment of sludge samples with a total petroleum hydrocarbon (TPH) content of 2243 mg/kg collected from a soil washing plant. The treatability studies were performed at the laboratory and pilot-real scales. The bioslurry assays yielded a TPH reduction efficiency of 57% and 65% in 28 days at the laboratory and pilot scale, respectively. In the landfarming assays, a TPH reduction of 85% in six months was obtained at laboratory scale and 42% in three months for the bioremediation performed in the full-scale. The efficiency of these processes was evaluated by ecotoxicity assessments. The toxic effects in the initial sludge sample were very low for most measured parameters. After the remediation treatments, a decrease in toxic effects was observed in earthworm survival and in carbon mineralisation. The results showed the applicability of two well known bioremediation technologies on these residues, this being a novelty.

Incidence of microflora and of ochratoxin A in green coffee beans (Coffea arabica)

Coffee is produced in tropical countries around the Equator where climatic conditions are favourable for fungal development and mycotoxin production; however, mycotoxins do not only occur in the tropical countries. The aim was to evaluate the mycoflora and possible incidence of ochratoxin A (OTA) in 60 samples of green coffee beans from Brazil. The mycological evaluation was carried out using a conventional method and the OTA was determined using sequential phenyl silane and immunoaffinity column cleanup followed by HPLC. The detection limit was 0.2 microg kg(-1). Practically all samples (91.7%) were contaminated with moulds. The dominant fungal genus was Aspergillus, including A. niger (83.3%), A. ochraceus (53.3%) and A. flavus (25.0%). The occurrence and the levels of the genus Cladosporium (16.6%) and Penicillium (10.0%) were substantially lower than Aspergilli. Twenty samples (33.3%) of 60 were contaminated with the toxin at levels ranging from 0.2 to 7.3microg kg(-1). The average concentration was 2.38 microg kg(-1). All positive samples showed OTA levels below the limit suggested by the European Union (8 microg kg(-1)).