Mortality among methicillin-resistant Staphylococcus aureus carriers in long-term care facilities

INTRODUCTION

Little is known about the natural course of patients with chronic stable illnesses colonized with methicillin-resistant Staphylococcus aureus (MRSA). The aim is to determine the impact of MRSA colonization in mortality among long-term health care facility (LTHCF) residents.

METHOD

A multicenter, prospective, observational study was designed. Residents in 4 LTHCFs were classified according to MRSA carriage status and followed for 12 months. Treatment consisted of 5 days of nasal mupirocin in MRSA carriers.

RESULTS

Ninety-three MRSA-carriers among 413 residents were identified. Thirty-one MRSA-colonized patients died during the study period, 11 of whom from an infectious disease. Independent predictors of their higher mortality rates included heart failure, current neoplasm, MRSA carriage and COPD at 3 months and these same factors plus stroke, Bar-thel index <40, pressure ulcers, and older age at 12 months. MRSA-persistence was 35% and 62.5% at 3 and 12 months, respectively.

CONCLUSIONS

MRSA colonization among frail LTHCFs residents is highly prevalent, and is associated with higher mortality. Despite treatment of MRSA carriers, many remained colonized. Factors that promote persistence of MRSA colonization, and the impact of their modification on mortality rates in these patients, need further investigation.

Prevalence and risk factors for meticillin-resistant Staphylococcus aureus in an acute care hospital and long-term care facilities located in the same geographic area

To determine the prevalence and risk factors (RF) for methicillin-resistant Staphylococcus aureus (MRSA) during stay in 1 acute care hospital (ACH) and 4 long-term care facilities (LTCF). After obtaining the informed consent, nasal and skin ulcer swabs were taken and a survey was conducted to determine RF for MRSA. Six hundred and ninety nine patients were included, 413 LTCF and 286 ACH patients and MRSA prevalence were 22.5% and 7.3% respectively. MRSA was located in the nares, skin ulcers, and in both in 61.4%, 21.1%, and 17.5%. Among MRSA carriers, 81% of the ACH and 66.7% of the LTCF patients were only colonized. The multivariate analysis for the ACH revealed the following factors to be associated with MRSA: referral from an LTCF (OR 4.84), pressure ulcers (OR 4.32), a Barthel score < 60 (OR 2.60), and being male (OR 5.21). For the LTCF: urinary catheterisation (OR 3.53), pressure ulcers (OR 2.44), other skin lesions (OR 2.64), antibiotic treatment in ≤ 6 months, (OR 2.23), previous MRSA colonization (OR 2.15), and a Barthel score <20 (OR 1.28). Molecular typing identified 2 predominant clones Q, P, present in all centres. No relationship was found between clones and antibiotic susceptibility.

IN CONCLUSION

MRSA prevalence is high in all centres but is 3 times greater in LTCF. The risk factors most strongly associated with MRSA were pressure ulcers and a stay in an LTCF. We propose preventive isolation in these cases.

Safety of positive-pressure valve connectors in arterial catheters inserted into critically ill patients

Needleless valve connectors were introduced to avoid needlestick injuries in healthcare workers but some concerns exist about their microbiological safety. A randomised controlled trial was performed to assess hub colonisation affecting positive-pressure valve connectors (PPVCs) compared to conventional caps used for radial arterial catheters inserted into critically ill patients. Patients were randomly assigned either to the PPVC (Smartsite Plus positive bolus valve) or to the conventional cap group. Only catheters inserted for >24h were analysed. Of 100 consecutive arterial lines, 80 were inserted for >24h (mean insertion duration 5.8 days), 41 in the PPVC group and 39 in the conventional cap group. Catheter hubs were colonised in eight cases in the control group (20.5%) and in one case in the PPVC group (2.4%). Hub colonisation was caused by coagulase-negative staphylococci in all cases. No attributable bacteraemia was observed. In multivariate analysis, PPVC (odds ratio: 0.09; 95% confidence interval: 0.1-0.79; P=0.03) and use of the line for continuous haemodynamic monitoring (0.16; 0.03-0.89; P=0.037) were independently associated with a lower incidence of hub colonisation.

Malaria importada: revisión epidemiológica y clínica de una enfermedad emergente cada vez más frecuente

OBJECTIVE

To describe the epidemiology, clinical and laboratory features and outcome of children younger than 15 years with malaria in our hospital.

MATERIAL AND METHODS

A retrospective case review of all children admitted to our hospital with malaria between 1997 and 2005 was performed. The following epidemiological data were analyzed: age, sex, nationality of the child and of the family, country and date of trip, chemoprophylaxis used, clinical features, laboratory parameters (hemogram and biochemistry), type of plasmodium and degree of parasitization, treatment, associated diseases, length of hospital stay, and outcome.

RESULTS

A total of 24 children (16 boys) were diagnosed (median age, 6.5 years). All of the patients were immigrants or were the children of sub-Saharian immigrants. Thirteen patients had traveled to a malaria-endemic country during the summer holidays. Eleven children started chemoprophylaxis, but only two completed the whole course. The most common symptoms were fever (21 patients) and gastrointestinal symptoms (16 patients). Nineteen patients had anemia and six had thrombocytopenia. The most common species identified was Plasmodium falciparum (19 patients). After treatment, outcome was satisfactory in 21 patients. One patient had recurrence at 3 months, another showed sequelae, and one died after 30 days.

CONCLUSIONS

Most children with imported malaria in our area were immigrants or the children of immigrants. Although treatment response is usually satisfactory, rapid diagnosis of this disease in the emergency room of any hospital capable of treating these patients is required.

Sporadic and epidemic community legionellosis: two faces of the same illness

The present study compares the risk factors, presentation and outcome of community-acquired Legionella pneumophila pneumonia in 138 sporadic-case patients (1994-2004) and 113 outbreak-case patients (2002) treated in two hospitals in Catalonia (Spain) since urinary antigen assays were adopted. Univariate and multivariate analysis were performed to compare epidemiological and clinical features, blood chemistry values, radiological findings and outcome of sporadic and epidemic legionnaires' disease. Univariate analysis showed that male sex, chronic lung disease, HIV infection and immunosuppressive therapy prevailed in sporadic cases. Presentation with respiratory symptoms, confusion and blood chemistry alterations, such as hyponatraemia, aspartate aminotransferase and blood urea nitrogen elevation, and partial pressure of oxygen P(O)(2) <7.98 KPa (60 mmHg) were also more frequent in sporadic cases, while headache prevailed in outbreak cases. Sporadic cases had a greater delay in treatment, were more severe and had a worse outcome than epidemic cases. Multivariate analysis showed significant differences in sex, chronic lung disease, HIV infection and headache. The clinical and outcome differences between the two groups may be explained by the detection of milder forms of legionnaires' disease, the earlier treatment and the lower severity of underlying disease in the outbreak cases.

A community outbreak of Legionnaires' disease: evidence of a cooling tower as the source

A community outbreak of Legionella pneumonia in the district of Cerdanyola, Mataró (Catalonia, Spain) was investigated in an epidemiological, environmental and molecular study. Each patient was interviewed to ascertain personal risk-factors and the clinical and epidemiological data. Isolates of Legionella from patients and water samples were subtyped by pulsed-field gel electrophoresis. Between 7 August and 25 August 2002, 113 cases of Legionella pneumonia fulfilling the outbreak case definition criteria were reported, with 84 (74%) cases being located within a 500-m radius of the suspected cooling tower source. In this area, the relative risk of being infected was 54.6 (95% CI 25.3-118.1) compared with individuals living far from the cooling tower. Considering the population residing in the Cerdanyola district (28,256 inhabitants) as a reference population, the attack rate for the outbreak was 399.9 cases/100,000 inhabitants, and the case fatality rate was 1.8%. A single DNA subtype was observed among the ten clinical isolates, and one of the subtypes from the cooling tower matched exactly with the clinical subtype. Nine days after closing the cooling tower, new cases of pneumonia caused by Legionella ceased to appear. The epidemiological features of the outbreak, and the microbiological and molecular investigations, implicated the cooling tower as the source of infection.

Isolation of an amikacin-resistant Escherichia coli strain after tobramycin treatment of previous recurrent episodes of respiratory tract infections caused by Pseudomonas aeruginosa

Amikacin-resistant Escherichia coli strains are isolated rarely from clinical samples. In the present study, investigation of an amikacin-resistant clinical isolate of E. coli demonstrated the presence of two class 1 integrons carrying the aacA4 gene plus the aacA7 gene, and the dfrA17 gene plus the aadA5 gene, respectively. Resistance to amikacin in this E. coli isolate was related to the presence of both aacA4 and aacA7.

Molecular characterization of ciprofloxacin resistance of gonococcal strains in Spain

BACKGROUND

Over the past several years, the emergence of gonococcal isolates with intermediate or full resistance to fluoroquinolones has become a significant concern in several countries, including Spain.

GOAL

The goal was to determine the occurrence of ciprofloxacin resistance among Neisseria gonorrhoeae strains in Spain during 2000 to 2001 and determine the frequency and patterns of mutations at gyrA, gyrB, and parC genes in these isolates.

STUDY DESIGN

Eleven ciprofloxacin-resistant strains (with MICs ranging from 1 to 64 micrograms/mL) and two intermediate isolates (with MICs of 0.12 and 0.5 microgram/mL) were found. Mutations were identified by polymerase chain reaction and direct sequencing of the amplified products.

RESULTS AND CONCLUSIONS

Alterations at Ser-91 and Asp-95 in GyrA were detected in all strains except one, an isolate for which the MIC was 0.12 microgram/mL. Alterations in ParC were more variable, and there was no clear correlation between the number of parC mutations and the level of resistance. No alterations at gyrB gene associated with ciprofloxacin resistance were found. The resistance was distributed among different types of strains, suggesting that the increase in the incidence of ciprofloxacin-resistant strains in Spain was not exclusively due to the appearance of a single-strain outbreak.

Comparative, clinico-epidemiologic study of Schistosoma mansoni infections in travellers and immigrants in Spain

The study presented here aimed to contrast the marked clinical differences in the presentation of Schistosoma mansoni-induced infection between immigrants and travellers entering Spain from endemic regions, and to elucidate the therapeutic implications of these infections. A total of 200 African immigrants and 80 travellers with schistosomiasis were included in the study. Among the immigrants, 25 patients were diagnosed with Schistosoma mansoni infection; 15 presented with nonspecific symptoms, and 10 were asymptomatic. Hepatosplenomegaly was observed in nine. Among the travellers, 14 were diagnosed with Schistosoma mansoni infection; four were asymptomatic, four had Katayama syndrome, four had diarrhoea, and two had prostatitis. All of the patients were treated with praziquantel. Patients diagnosed with Katayama syndrome received praziquantel and dexamethasone for 3 days, with the praziquantel treatment being repeated at 3-4 weeks. The significant differences observed in the clinical presentation of Schistosoma mansoni-induced infection, indicate that a well-differentiated therapeutic strategy is required when this infection is diagnosed in a non-immune (traveller) or a semi-immune (immigrant) patient.

Epidemiology of community-acquired pneumonia in adults: a population-based study

In this prospective study, the authors assessed the incidence, aetiology, and outcome of patients with community-acquired pneumonia in the general population. From December 1993 to November 1995, a study was performed in a mixed residential-industrial urban population of the "Maresme" region in Barcelona, Spain. All subjects > or =14 yrs of age (annual average population size 74,368 inhabitants) with clinically suspected community-acquired pneumonia were registered. All cases were re-evaluated by chest radiographs on the 5th day of illness and at monthly intervals until complete recovery. Urine and blood samples were obtained for culture and antigen detection. When lower respiratory tract secretions were obtained, these were also cultured. There were 241 patients with community-acquired pneumonia, with an annual incidence rate of 1.62 cases (95% confidence interval, 1.42-1.82) per 1,000 inhabitants. Incidence rates increased by age groups and were higher in males than in females. Of 232 patients with aetiological data, 104 had an identifiable aetiology. A total of 114 pathogens were found (single pathogen 94, two pathogens 10). There were 81 episodes of bacterial infection and 33 of viral infection. The most common pathogens were Streptococcus pneumoniae, Chlamydia pneumoniae, and influenza A and B viruses. No case of Hantavirus infection was found. The rate of hospital admission was 61.4% with a mean+/-SD length of 11.7+/-10.1 days, a mean period of 23.0+/-14.3 days inactivity, and an overall mortality rate of 5%. The high rate of hospital admission, prolonged stay in hospital, and long period of inactivity all continue to constitute a social and health care burden of community-acquired pneumonia.

[Changes in the sensitivity of Escherichia coli to 6 antimicrobial agents during the last 12 years. Group of Microbiologists of County Hospitals of Catalonia]

OBJECTIVE

To study the current state and development in the sensitivity of Escherichia coli during 12 years, in order to find the use of 6 antimicrobials.

DESIGN

A descriptive study of the annual sensitivity percentages of E. coli strains isolated from clinical samples between 1984 and 1995.

SETTING

Microbiology Laboratories in 15 County Hospitals in the province of Barcelona.

PATIENTS AND PARTICIPANTS

E. coli strains, isolated from clinically significant samples, were studied for sensitivity against antimicrobials.

MEASUREMENTS AND MAIN RESULTS

Cefuroxime and Gentamicin had in vitro sensibility above 94%. Current sensitivity of E. coli to Norfloxacin was 85%. Amoxicillin-Clavulanic acid maintained its sensitivity at about 80% with few variations. Ampicillin and Co-trimoxazole had steady sensitivity figures, always below 50 and 70%, respectively.

CONCLUSIONS

Progressive decrease in the sensitivity of E. coli strains to Norfloxacin was observed. There was excellent sensitivity to Cefuroxime and Gentamicin.

[Multicenter study of the Rosco-Neisseria system for the identification of pathogenic neisserias and Branhamella catarrhalis]

The commercial Rosco-Neisseria system was evaluated in the identification of 228 oxidase-positive Gram-negative diplococci and it was compared with conventional tests. The procedure detects gamma-glutamyl aminopeptidase, ONPG, tributyrin hydrolysis, and sensitivity to the disk of 10 micrograms of colistin. A correct identification was obtained in the 65 strains of Neisseria gonorrhoeae, the 33 of N. meningitidis, the 12 of N. lactamica, and the 56 of B. catarrhalis. The method was also able to discriminate 54 out of the 62 strains of nonpathogenic Neisseria. However, the 7 strains of Neisseria polysaccharea and one strain of N. subflava biovar perflava were erroneously identified as N. gonorrhoeae. None of the latter was superoxol positive in contrast with the 100% of cases of gonococcal strains. The Rosco-Neisseria system is simple and inexpensive but it should be applied on specimens that grow on selective media for gonococci (such as Thayer-Martin and others) and it should be complemented by superoxol test.