Impact of De-escalation on Prognosis of Patients With Bacteremia due to Enterobacteriaceae: A Post Hoc Analysis From a Multicenter Prospective Cohort

Background

More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. The aims of this study were to investigate predictors of de-escalation and its impact on the outcome of patients with bloodstream infection due to Enterobacteriaceae (BSI-E).

Methods

A post hoc analysis was performed on a prospective, multicenter cohort of patients with BSI-E initially treated with ertapenem or antipseudomonal β-lactams. Logistic regression was used to analyze factors associated with early de-escalation (EDE) and Cox regression for the impact of EDE and late de-escalation (LDE) on 30-day all-cause mortality. A propensity score (PS) for EDE vs no de-escalation (NDE) was calculated. Failure at end of treatment and length of hospital stay were also analyzed.

Results

Overall, 516 patients were included. EDE was performed in 241 patients (46%), LDE in 95 (18%), and NDE in 180 (35%). Variables independently associated with a lower probability of EDE were multidrug-resistant isolates (odds ratio [OR], 0.50 [95% confidence interval {CI}, .30–.83]) and nosocomial infection empirically treated with imipenem or meropenem (OR, 0.35 [95% CI, .14–.87]). After controlling for confounders, EDE was not associated with increased risk of mortality; hazard ratios (HR) (95% CIs) were as follows: general model, 0.58 (.25–1.31); model with PS, 0.69 (.29–1.65); and PS-based matched pairs, 0.98 (.76–1.26). LDE was not associated with mortality. De-escalation was not associated with clinical failure or length of hospital stay.

Conclusions

De-escalation in patients with monomicrobial bacteremia due to Enterobacteriaceae was not associated with a detrimental impact on clinical outcome.

Factors associated with severity in invasive community-acquired Staphylococcus aureus infections in children: a prospective European multicentre study

Staphylococcus aureus is the main pathogen responsible for bone and joint infections worldwide and is also capable of causing pneumonia and other invasive severe diseases. Panton-Valentine leukocidin (PVL) and methicillin-resistant S. aureus (MRSA) have been studied as factors related with severity in these infections. The aims of this study were to describe invasive community-acquired S. aureus (CA-SA) infections and to analyse factors related to severity of disease. Paediatric patients (aged 0-16 years) who had a CA-SA invasive infection were prospectively recruited from 13 centres in 7 European countries. Demographic, clinical and microbiological data were collected. Severe infection was defined as invasive infection leading to death or admission to intensive care due to haemodynamic instability or respiratory failure. A total of 152 children (88 boys) were included. The median age was 7.2 years (interquartile range, 1.3-11.9). Twenty-six (17%) of the 152 patients had a severe infection, including 3 deaths (2%). Prevalence of PVL-positive CA-SA infections was 18.6%, and 7.8% of the isolates were MRSA. The multivariate analysis identified pneumonia (adjusted odds ratio (aOR) 13.39 (95% confidence interval (CI) 4.11-43.56); p 0.008), leukopenia at admission (<3000/mm(3)) (aOR 18.3 (95% CI 1.3-259.9); p 0.03) and PVL-positive infections (aOR 4.69 (95% CI 1.39-15.81); p 0.01) as the only factors independently associated with severe outcome. There were no differences in MRSA prevalence between severe and nonsevere cases (aOR 4.30 (95% CI 0.68- 28.95); p 0.13). Our results show that in European children, PVL is associated with more severe infections, regardless of methicillin resistance.

Catheter-related Mycobacterium fortuitum bloodstream infection: rapid identification using MALDI-TOF mass spectrometry

We present the case of a 6-year-old boy diagnosed with stage III mediastinal Non Hodgkin Lymphoblastic T cell Lymphoma who suffered from catheter-related bloodstream infection (CRBI) due to Mycobacterium fortuitum whilst receiving chemotherapy. Isolation of this rare pathogen was done directly from blood culture and identification was made rapidly within 48 h using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectro-metry as well as specific polymerase chain reaction (PCR)-reverse hybridization method. This allowed prompt directed antibiotic therapy apart from central venous catheter removal and resulted in an excellent clinical response. This case highlights the potential benefit of using MALDI-TOF mass spectrometry, a fast, cost-effective and precise methodology, in the diagnosis and subsequent management of invasive bacterial infection.

Global impact of an educational antimicrobial stewardship programme on prescribing practice in a tertiary hospital centre

The misuse of antibiotics has been related to increased morbidity, mortality and bacterial resistance. The development of antimicrobial stewardship programmes (ASPs) has been encouraged by scientific societies as an essential measure. An educational, institutionally supported ASP was developed in our tertiary-care centre. Local guidelines on the management of infectious syndromes were created. Antimicrobial prescriptions were chosen arbitrarily weekly and counselling interviews by expert clinicians were carried out, using a paedagogic, non-restrictive methodology. Satisfaction with the interview was assessed using anonymous questionnaires. The appropriateness of antimicrobial prescriptions as well as consumption was assessed prospectively throughout the year. Feedback regarding the correct use of treatments was communicated to each participating department periodically. The improvement in antimicrobial prescription was included among the annual objectives linked to economic incentives in every department. A total of 1206 counselling interviews were carried out during the first year. Fifty-three per cent of antimicrobial prescriptions (176/332) were inappropriate when the programme started. The rate of inappropriate prescriptions continuously declined to 26.4% (107/405) in the fourth trimester (p <0.001; RR = 0.38; 95% CI, 0.23-0.43). Antimicrobial consumption decreased from 1150 defined daily doses (DDDs) per 1000 occupied bed-days in the first trimester to 852 DDDs in the fourth, reflecting a reduction in antimicrobial expenditures of 42%. A total of 352 satisfaction questionnaires were received and 98% described the advice as positive. In conclusion, the implementation of an education-based ASP achieved a significant improvement in all antimicrobial prescriptions in the centre and a reduction in antimicrobial consumption, even when no restrictive measures were implemented. The programme was highly accepted by all prescribers.

Mortality and hospital stay related to coagulase-negative Staphylococci bacteremia in non-critical patients

OBJECTIVES

To describe the morbidity and mortality related to coagulase-negative Staphylococci (CNS) bacteremia in non-critical patients.

METHODS

Prospective, matched case-control study nested in a cohort. Patients with CNS bacteremia and no other isolate in blood cultures during their admission were defined as cases. Each case was matched by age, sex and area of hospitalization to one control. A 30-day follow-up was performed. Mortality and hospital stay were defined as endpoints.

RESULTS

105 cases and 105 controls were included. All cases carried intravascular catheters at the time of inclusion. Cases presented higher mortality compared to controls (14.3% vs. 4.8%), although this association was not independent in a multivariate analysis (p = 0.11). CNS bacteremia was independently associated with longer hospital stay (mean 12 vs. 8.5 days, p = 0.008). Moreover, when patients with CNS bacteremia were specifically analyzed, the persistence of fever (p = 0.005) and inappropriate empirical treatment (p = 0.04) were independently related to mortality.

CONCLUSION

We did not observe increased mortality attributable to CNS bacteremia, although it was associated with longer hospitalizations. Early appropriate empirical antibiotic therapy pending blood culture results might improve the outcome of patients with CNS bacteremia. Close follow-up is recommended if fever persists beyond 72 h.

Clinical and molecular epidemiology of meticillin-resistant Staphylococcus aureus causing bacteraemia in Southern Spain

BACKGROUND

Some molecular features of meticillin-resistant Staphylococcus aureus (MRSA) isolates causing invasive infections have been shown to have clinical implications. There is a need to monitor the situation using a combination of molecular and clinical data because, although MRSA clones tend to predominate over wide geographical areas, clonal shifts may take place.

AIM

To study the epidemiological features and perform molecular characterization of a retrospective cohort of 98 cases of nosocomial and healthcare-associated MRSA bacteraemia in 10 hospitals in Andalusia, Spain.

METHODS

Relatedness of isolates was investigated using pulsed-field gel electrophoresis (PFGE), S. aureus protein A (spa) typing and clonal complex (CC) assignment. Staphylococcal chromosomal cassette mec (SCCmec) type and accessory gene regulator (agr) group were studied by polymerase chain reaction. agr function was assessed.

RESULTS

Most isolates were CC5, SCCmec type IV and agr group II. The most common spa type was t067. Six major clusters were identified by PFGE. Six small clusters of epidemiologically related cases sharing isolates from the same PFGE subtype were identified. Five percent of isolates had a vancomycin minimum inhibitory concentration (MIC) of 2 μg/mL on broth microdilution, although 44% had an MIC >1 μg/mL on E-test. Variables independently associated with MIC >1 mg/L on E-test were surgery during present admission and Charlson index ≥2.

CONCLUSION

A specific CC that has been predominant in Spain over the last decade caused most of the cases in this study. PFGE was more discriminatory than spa typing in showing clusters of epidemiologically related cases. Some patient features were associated with vancomycin MIC >1 mg/L on E-test.

[Diagnosis and treatment of refractory sprue]

Celiac disease is a gluten-sensitive enteropathy characterized by villous atrophy that is reversed by gluten withdrawal. A minority of these patients is resistant to a gluten-free diet or, after a period of remission, they experience relapse despite continued adherence to treatment, which is called unclassified sprue or refractory sprue.The prognosis of refractory sprue may be poor: patients may die of severe malabsorption or from the development of an enteropathy-associated T-cell lymphoma. We report a 72-year-old-woman with a diagnosis of refractory sprue who responded well to treatment with corticosteroids and a gluten-free diet.

[Serologic response against hepatitis C virus as a predictive factor to the treatment with interferon]

AIM

Serologic response of patients with chronic hepatitis C (CHC) was studied as a predictor of response to IFN therapy and we evaluated the correlation between such response with gender, risk factor, serum ferritin, GGT, Knodell's index and fibrosis.

MATERIALS AND METHODS

A study was carried out in 40 patients with CHC who were treated with interferon-alpha 3 MU 3 times weekly 48 weeks. The diagnosis of hepatitis C was made based upon Inmuno-Blot (core, NS3, NS4 y NS5) and confirmed by detection of HCV-RNA in serum. Responses were evaluated (normal ALT and undetectable HCV-RNA in serum) at three months, at the end of treatment and six months after treatment.

RESULTS

No significant differences were observed in responses at three months with regard to gender (47% males responded versus 55% females, n.s.), source of infection (50% intravenous drug users versus 50% non intravenous drug users; n.s.) and GGT level (50% with high levels versus 50% with normal levels, n.s.); however 25% of patients with high level of serum iron responded versus 59% with normal values (p = 0.04) and 28% of patients with fibrosis at liver histopathology responded versus 82% without fibrosis (p = 0.0006). No differences were observed at the response rates with regard to levels of core (20.1 SD:4 versus 19.5 SD:2.2, n.s.), NS3 (18.6 SD:7 versus 17.1 SD:7.3, n.s.) and NS4 (14.3 SD:7.7 versus 10.5 SD:9.2, n.s.). However NS5 levels in responders were 2.5 (0-16) versus 5.2 (0-16.5) in nonresponders (p < 0.05) and score in Knodell's index was 6.1 SD:2.6 in responders versus 9.2 SD:2.4 in nonresponders (p = 0.006). 47% of responders relapsed 6 months after the end of treatment with IFN.

CONCLUSIONS

Titers of anti-NS5 showed predictive value of response as opposed to anti-core, anti-NS3 and anti-NS4 and it may justify its determination in the assessment of a patient with CHC at centers without capacity for measuring genotype and viral load. Low level of serum iron and Knodell's index like absence of fibrosis at liver histopathology were also variables with predictive value of response, as opposed to gender, GGT level and source of infection.

[The epidemiology of Q fever in the northern area of Huelva, Spain]

OBJECTIVE

The aim of the present study is to know the prevalence, incidence and clinical presentation of the acute Q fever in the north of the Huelva district.

METHODOLOGY

a) Prevalence: 1,654 serum were randomly collected from the health district and distributed by their origin, age and sex. The methodology used was the indirect immunofluorescence, Coxiella burnetii phase II as antigen. Were regarded as positives those serum whose titles were equal or higher to 80; b) Incidence: prospective study of every case treated in hospital during 1996-1997 plus every referred patient from the different "Health Centers". An acute case of Q fever was established as a feverish syndrome of more than 2 days plus a title equal or higher to 320 against C. burnetti phase II antigen, and c) Clinical data: all the patients were clerked and similar form was filled up including the following items: pneumonia, hepatitis, headache, persistent fever, etc.

RESULTS

a) Prevalence: it was 5.08%, more frequent in men than in women; b) Incidence: 21 new cases over two years, an incidence of 12.70 cases per 100,000 population, and c)

CLINICAL PRESENTATION

feverish syndrome plus hepatitis in 100% of the cases, just two pneumonia were recorded and in 4 cases the clinical picture was associated to immunological symptoms with persistent fever.

CONCLUSION

A discrepancy between incidence and prevalence has been pointed out which makes us think that the majority of the Q fever cases in this area debut as a self restricted feverish syndrome which does not require specialized treatment.

[Eradication of Helicobacter pylori by triple therapy in ulcerous patients: the role of endoscopy and antibiotic sensitivity]

BACKGROUND

A protocol was conducted to evaluate the compliance and results of Helicobacter pylori infection treatment in patients with ulcer disease. To know the metronidazole, clarithromycin and amoxicillin activities of Helicobacter pylori strains from such patients.

PATIENTS AND METHODS

35 patients with ulcer disease (27 duodenal ulcer and 8 gastric ulcer) were studied. Diagnosis of Helicobacter pylori infection was performed by urease test and culture of mucosal gastric samples from patients undergoing endoscopy. The patients received the following treatment during 7 days: omeprazole (20 mg bid), clarithromycin (500 mg bid) and amoxicillin (1 g bid), OCA x 7. Susceptibility was determined by E-test system on Wilkins-Chalgren blood agar and read after 5 days.

RESULTS

22/24 patients who had completed the protocol design eradicated Helicobacter pylori (91.7%), 11 patients (31.4%) refused second endoscopy to verify control of eradication. After treatment 10 patients presented with pyrosis "de novo" (28%). The overall metronidazol, claritromycin and amoxicillin resistance rate was 50%, 1.5% and 0% respectively.

CONCLUSIONS

OCA x 7 treatment obtains a eradication rate higher than 90% in our patients with ulcer disease, despite smoking habit, but with a significative number of patients presenting pyrosis after treatment. We recommend a non-endoscopy method to verify eradication rate, because of its poor acceptance. 3. Metronidazol resistance rate is high in our series but clarithromycin susceptibility is maintained.

[The first description of infection by Actinomyces radingae]

BACKGROUND

To communicate at clinical value of an isolation of Actinomyces radingae from an ulcerated lesion the external supra-malleolus region.

MATERIAL AND METHODS

We proceed to study the clinical and bacteriological value of an isolated aerobic gram positive rod in pure culture obtained from an ulcerated lesion ocated at the external supra-malleolus region of a 92 years old woman in whom there was later evidence of an epidermoid carcinoma. Surgical and antibiotic treatment were needed. The biochemistry characterization of the isolated was carried out according to the schemes of Weaver-Hollis and Funke et al, as well as the characterization of the fat acids of their cellular wall by gas-liquid chromatography.

RESULTS

The isolated was identified as Actinomyces radingae. The patient follow-up was satisfactory after the treatment.

CONCLUSION

The first infection description by Actinomyces radingae is reported wherein its pathological value is evident as it is isolated in pure culture.