Search

La neumonía es uno de los síndromes infecciosos más frecuentes y una importante causa de mortalidad y de consumo de recursos. Constituido por expertos en Enfermedades Infecciosas y Microbiología, el Grupo OPENIN (Optimización de procesos clínicos para el diagnóstico y tratamiento de infecciones) tiene por objeto la generación de recomendaciones que contribuyan a mejorar el abordaje de procesos con elevado impacto sobre el sistema sanitario a partir de una revisión crítica de la evidencia científica disponible. La primera reunión del Grupo (celebrada en octubre de 2023) trató de contestar las siguientes preguntas: ¿cómo podemos optimizar el diagnóstico sindrómico y etiológico de la neumonía?, ¿es posible reducir de forma segura la duración del tratamiento antibiótico?, y ¿tienen un papel las estrategias de inmunomodulación basadas en el tratamiento adyuvante con esteroides, macrólidos o inmunoglobulinas? La presente revisión sintetiza la literatura revisada para aquella ocasión y ofrece una serie de recomendaciones de expertos.

El virus de la gripe ha acompañado al ser humano desde tiempo inmemorial, en forma de epidemias anuales y pandemias ocasionales. Se trata de una infección respiratoria con múltiples repercusiones sobre la vida de las personas a nivel individual y social y supone una importante sobrecarga para el sistema sanitario. El presente documento de consenso surge de la colaboración de diversas sociedades científicas españolas implicadas en la atención de la infección por el virus de la gripe. Las conclusiones extraídas se han fundamentado en las evidencias de mayor calidad disponibles en la literatura científica y, en su defecto, en la opinión de los expertos convocados. En el documento de consenso se abordan los aspectos clínicos, microbiológicos, terapéuticos y preventivos (respecto de la prevención de la transmisión y en relación con la vacunación) de la gripe, tanto en población pediátrica como en adultos. Este documento de consenso aspira a contribuir a facilitar el abordaje clínico, microbiológico y preventivo de la infección por el virus de la gripe y, consecuentemente, a disminuir sus importantes consecuencias sobre la morbimortalidad de la población.

The influenza virus has accompanied humans since time immemorial, in the form of annual epidemics and occasional pandemics. It is a respiratory infection with multiple repercussions on people's lives at an individual and social level, as well as representing a significant burden on the health system. This Consensus Document arises from the collaboration of various Spanish scientific societies involved in influenza virus infection. The conclusions drawn are based on the highest quality evidence available in the scientific literature and, failing that, on the opinion of the experts convened. The Consensus Document addresses the clinical, microbiological, therapeutic, and preventive aspects (with respect to the prevention of transmission and in relation to vaccination) of influenza, for both adult and pediatric populations. This Consensus Document aims to help facilitate the clinical, microbiological, and preventive approach to influenza virus infection and, consequently, to reduce its important consequences on the morbidity and mortality of the population.

Treatment failure occurs in about 25% of patients with methicillin-susceptible Staphylococcusaureus(MSSA) bacteremia. We assessed whether cloxacillin plus fosfomycin achieves better treatment success than cloxacillin alone in hospitalized adults with MSSA bacteremia. We conducted a multicenter, open-label, phase III–IV superiority randomized clinical trial. We randomly assigned patients (1:1) to receive 2 g of intravenous cloxacillin alone every 4 h or with 3 g of intravenous fosfomycin every 6 h for the initial 7 days. The primary endpoint was treatment success at day 7, a composite endpoint with the following criteria: patient alive, stable or with improved quick Sequential Organ Failure Assessment score, afebrile and with negative blood cultures for MSSA, adjudicated by an independent committee blinded to treatment allocation. We randomized 215 patients, of whom 105 received cloxacillin plus fosfomycin and 110 received cloxacillin alone. We analyzed the primary endpoint with the intention-to-treat approach in 214 patients who received at least 1 day of treatment. Treatment success at day 7 after randomization was achieved in 83 (79.8%) of 104 patients receiving combination treatment versus 82 (74.5%) of 110 patients receiving monotherapy (risk difference 5.3%; 95% confidence interval (CI), –5.95–16.48). Secondary endpoints, including mortality and adverse events, were similar in the two groups except for persistent bacteremia at day 3, which was less common in the combination arm. In a prespecified interim analysis, the independent committee recommended stopping recruitment for futility prior to meeting the planned randomization of 366 patients. Cloxacillin plus fosfomycin did not achieve better treatment success at day 7 of therapy than cloxacillin alone in MSSA bacteremia. Further trials should consider the intrinsic heterogeneity of the infection by using a more personalized approach. ClinicalTrials.gov registration: NCT03959345.

Introduction: The profiles of patients with COVID-19 have been widely studied, but little is known about differences in baseline characteristics and in outcomes between subjects with a ceiling of care assigned at hospital admission and subjects without a ceiling of care. The aim of this study is to compare, by ceiling of care, clinical features and outcomes of hospitalized subjects during four waves of COVID-19 in a metropolitan area in Catalonia. Methods: Observational study conducted during the first (March–April 2020), second (October–November 2020), third (January–February 2021), and fourth wave (July–August 2021) of COVID-19 in five centers of Catalonia. All subjects were adults (> 18 years old) hospitalized with a proven SARS-CoV-2 infection and with therapeutic ceiling of care assessed by the attending physician at hospital admission. Results: A total of 5813 subjects were analyzed. Subjects with a ceiling of care were mainly older (difference in median age of 20 years), with more comorbidities (Charlson index 3 points higher) and with fewer clinical signs at baseline than patients without a ceiling of care. Some features of their clinical profiles changed among waves. There were differences in treatments received during hospital admission across waves, but not between subjects with and without a ceiling of care. Subjects with a ceiling of care had a death incidence more than four times the death incidence of subjects a without a ceiling of care (risk ratio (RR) ranging from 3.5 in the first wave to almost 6 in the third and fourth). Incidence of severe pneumonia and complications for subjects with a ceiling of care was around 1.5 times the incidence in subjects without a ceiling of care. Discussion: Analysis of hospitalized subjects with SARS-CoV-2 infection should be stratified according to therapeutic ceiling of care to avoid bias and outcome misestimation.

Introduction: In a large cohort of patients with Staphylococcus aureusbloodstream infection (SABSI), we aimed to analyze the incidence and risk factors for infective endocarditis (IE) among patients with active cancer (PAC) in comparison with those without cancer (PWC). Methods: Multicenter cohort study of patients with SABSI admitted to two tertiary care hospitals, from 2011 to 2019. PAC were defined as those with an active solid organ cancer or hematological malignancies. SABSI and S. aureusIE were compared between PAC and PWC. Results: Among 978 episodes of SABSI, 217 (22.2%) occurred in PAC. PAC were younger, had fewer comorbidities, carried cardiac devices less often, and had less community-acquired SABSI than PWC. Compared to PWC, PAC more frequently had catheter-related SABSI, less IE (2.8% vs 10.9%, p< 0.001) and osteoarticular infection (2.3% vs 14.3%, p< 0.001). Independent risk factors for IE were cardiopathy (aOR 4.392, 95% CI 2.719–7.094) and persistent bacteremia (aOR 3.545, 95% CI 2.159–5.820). Thirty-day mortality was high, and similar between groups (24.2% vs 25.5%, p= 0.282). Conclusions: PAC with SABSI developed IE less frequently than PWC did. This finding seems related to the differences in baseline characteristics and may have significant clinical implications, such as transesophageal echocardiography in PAC without cardiopathy or persistent bacteremia.

Legionellosis is the infection caused by bacteria of the genus Legionella, including a non-pneumonic influenza-like syndrome, and Legionnaires’ disease is a more serious illness characterized by pneumonia. Legionellosis is becoming increasingly important as a public health problem throughout the world; although it is an underreported disease, studies have consistently documented a high incidence. In addition, health costs associated with the disease are high. Diagnosis of Legionnaires’ disease is based mainly on the detection of Legionella pneumophilaserogroup 1 antigen in urine. However, there have been advances in detection tests for patients with legionellosis. New methodologies show greater sensitivity and specificity, detect more species and serogroups of Legionellaspp., and have the potential for use in epidemiological studies. Testing for Legionellaspp. is recommended at hospital admission for severe community-acquired pneumonia, and antibiotics directed against Legionellaspp. should be included early as empirical therapy. Inadequate or delayed antibiotic treatment in Legionellapneumonia has been associated with a worse prognosis. Either a fluoroquinolone (levofloxacin or moxifloxacin) or a macrolide (azithromycin preferred) is the recommended first-line therapy for Legionnaires’ disease; however, little information is available regarding adverse events or complications, or about the duration of antibiotic therapy and its association with clinical outcomes. Most published studies evaluating antibiotic treatment for Legionnaires’ disease are observational and consequently susceptible to bias and confounding. Well-designed studies are needed to assess the usefulness of diagnostic tests regarding clinical outcomes, as well as randomized trials comparing fluoroquinolones and macrolides or combination therapy that evaluate outcomes and adverse events.

Background and Objectives: Morbidity and mortality from serious infections are common in intensive care units (ICUs). The appropriateness of the antibiotic treatment is essential to combat sepsis. We aimed to evaluate pharmacokinetic/pharmacodynamic target attainment of meropenem and piperacillin/tazobactam administered at standard total daily dose as continuous infusion in critically ill patients without renal dysfunction and to identify risk factors of non-pharmacokinetic/pharmacodynamic target attainment. Results: We included 118 patients (149 concentrations), 47% had microorganism isolation. Minimum inhibitory concentration (MIC) [median (interquartile range, IQR) values in isolated pathogens were: meropenem: 0.05 (0.02–0.12) mg/l; piperacillin: 3 (1–4) mg/l]. Pharmacokinetic/pharmacodynamic target attainments (100%fCss≥1xMIC, 100%fCss≥4xMICand 100%fCss ≥ 8xMIC, respectively) were: 100%, 96.15%, 96.15% (meropenem) and 95.56%, 91.11%, 62.22% (piperacillin) for actual MIC; 98.11%, 71.70%, 47.17% (meropenem, MIC 2 mg/l), 95.83%, 44.79%, 6.25% (piperacillin, MIC 8 mg/l), 83.33%, 6.25%, 1.04% (piperacillin, MIC 16 mg/l) for EUCAST breakpoint of Enterobacteriaceaespp. and Pseudomonasspp. Multivariable linear analysis identified creatinine clearance (CrCL) as a predictive factor of free antibiotic concentrations (fCss) of both therapies (meropenem [β= − 0.01 (95% CI − 0.02 to − 0.0; p= 0.043)] and piperacillin [β= − 0.01 (95% CI − 0.02 to 0.01, p < 0.001)]). Neurocritical status was associated with lower piperacillin fCss[β = − 0.36 (95% CI − 0.61 to − 0.11; p = 0.005)]. Conclusion: Standard total daily dose of meropenem allowed achieving pharmacokinetic/pharmacodynamic target attainments in ICU patients without renal dysfunction. Higher doses of piperacillin/tazobactam would be needed to cover microorganisms with MIC > 8 mg/l. CrCL was the most powerful factor predictive of fCssin both therapies.

ObjectiveTo develop and validate a prediction model of mortality in patients with COVID-19 attending hospital emergency rooms.DesignMultivariable prognostic prediction model.Setting127 Spanish hospitals.ParticipantsDerivation (DC) and external validation (VC) cohorts were obtained from multicentre and single-centre databases, including 4035 and 2126 patients with confirmed COVID-19, respectively.InterventionsPrognostic variables were identified using multivariable logistic regression.Main outcome measures30-day mortality.ResultsPatients’ characteristics in the DC and VC were median age 70 and 61 years, male sex 61.0% and 47.9%, median time from onset of symptoms to admission 5 and 8 days, and 30-day mortality 26.6% and 15.5%, respectively. Age, low age-adjusted saturation of oxygen, neutrophil-to-lymphocyte ratio, estimated glomerular filtration rate by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, dyspnoea and sex were the strongest predictors of mortality. Calibration and discrimination were satisfactory with an area under the receiver operating characteristic curve with a 95% CI for prediction of 30-day mortality of 0.822 (0.806–0.837) in the DC and 0.845 (0.819–0.870) in the VC. A simplified score system ranging from 0 to 30 to predict 30-day mortality was also developed. The risk was considered to be low with 0–2 points (0%–2.1%), moderate with 3–5 (4.7%–6.3%), high with 6–8 (10.6%–19.5%) and very high with 9–30 (27.7%–100%).ConclusionsA simple prediction score, based on readily available clinical and laboratory data, provides a useful tool to predict 30-day mortality probability with a high degree of accuracy among hospitalised patients with COVID-19.

The immunosuppressive treatment that recipients receive from a solid organ transplantation hinders the defensive response to infection. Its transmission from the donor can cause dysfunction or loss of the graft and even death of the recipient if proper preventive measures are not established. This potential risk should be thoroughly evaluated to minimise the risk of infection transmission from donor to recipient, especially with organ transplantation from donors with infections, without increasing graft dysfunction and morbidity and mortality in the recipient. This document aims to review current knowledge about infection screening in potential donors and offer clinical and microbiological recommendations about the use of organs from donors with infection based on available scientific evidence.

Background: Short peripheral venous catheters are one of the most frequently used devices in hospitals. Peripheral venous catheter failure, defined as the unscheduled dysfunction of peripheral venous catheter, is common and frequently entails a new invasive procedure. Flushing the catheter maintains patency and could prolong peripheral venous catheter dwell time. The introduction of pre-filled saline flushing syringes as compared to manually filled saline flushing syringes could facilitate the frequency of catheter flushing, and subsequently it could reduce peripheral venous catheter failure rate.Objective: To demonstrate differences in overall peripheral venous catheter failure rates before and after the introduction of pre-filled saline flushing syringes and to assess the risk factors for peripheral venous catheter failure.Methods: Quasi-experimental design, before-and-after intervention study. Intervention: introduction of pre-filled saline syringes for flushing. Multicenter study conducted in medical and surgical wards of three European hospitals during a 9-month period (4 months pre-intervention, 5 months intervention). A multivariate Cox proportional model was used to identify factors associated with the occurrence of peripheral venous catheter failure.Results: Data from 3853 peripheral venous catheters in 1915 patients were analyzed. Compared to pre-intervention period, a significant decrease in peripheral venous catheter failure rate was observed in the intervention period (57% vs 43.4%, p < 0.001). Independent factors associated with peripheral venous catheter failure were as follows: Charlson score ⩾4 (hazard ratio: 1.648; 95% confidence interval: 1.069–2.527), days of hospital stay ⩾10 (hazard ratio: 1.468; 95% confidence interval: 1.172–1.837), and catheter “D” (hazard ratio: 1.758; 95% confidence interval: 1.058–2.919).Conclusion: The use of pre-filled saline syringes significantly reduced peripheral venous catheter failure and increased catheter dwell time. Thus, it is important to reinforce the use of the pre-filled syringes for flushing to reduce the incidence of peripheral venous catheters’ failure.

Febrile neutropenia is a very common complication in patients with hematological malignancies receiving chemotherapy, and is associated with high morbidity and mortality. Infections caused by multidrug-resistant bacteria have become a therapeutic challenge in this high-risk patient population, since inadequate initial empirical treatment can seriously compromise prognosis. However, reducing antimicrobial exposure is one of the most significant cornerstones in the fight against resistance. The objective of these new guidelines is to update recommendations for the initial management of hematological patients who develop febrile neutropenia in this scenario of multidrug resistance. The two participating Societies (the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica[Spanish Society of Infectious Diseases and Clinical Microbiology] and the Sociedad Española de Hematología y Hemoterapia[Spanish Society of Haematology and Haemotherapy]), designated a panel of experts in the field to provide evidence-based recommendations in response to common clinical questions. This document is primarily focused on bacterial infections. Other aspects related to opportunistic infections, such as those caused by fungi or other microorganisms, especially in hematopoietic stem cell transplantation, are also touched upon.

Aspergillusinfection is a significant cause of morbi-mortality in an at-risk population. The Study Group of Fungal Infections (GEMICOMED) from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) has reviewed announcements made in invasive aspergillosis management. We have organized our recommendations in such a way as to provide a guide in resolving different clinical situations concerning the entire spectrum of invasive diseases caused by Aspergillusin various populations. Diagnostic approach, treatment and preventions strategies are outlined. It is not our aim that these guidelines supplant clinical judgment with respect to specific patients; however, it is our objective to perform a comprehensive summary of quality of care evidence for invasive aspergillosis management in different settings.

ABSTRACTIntroduction: Case-fatality rates for Staphylococcus aureusbacteremia (SAB) remain unacceptably high and have improved only modestly in recent decades. Treatment of SAB is still a clinical challenge, especially if methicillin-resistant strains are involved. New drugs with anti-staphylococcal activity are currently available, and their role as alternatives to standard therapies is being investigated.Areas covered: In this review, we give an update of the current available antibiotics for the treatment of SAB. We provide information regarding the pharmacological characteristics, the accepted indications, and the most important adverse events of the old and new anti-staphylococcal agents, as well as the existing evidence on their use for the treatment of SAB.Expert opinion: The management of patients with SAB is very complex and needs a multidisciplinary approach. There are currently new available options for the treatment of methicillin-resistant SAB. However, more data from clinical trials are needed to assign specific roles to each antibiotic and to include them in the new antibacterial armamentarium. The role of combination therapy for the treatment of increasingly complex patients with SAB deserves thorough investigation.

Un grupo de expertos de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC) y de la Sociedad Española de Oncología Médica (SEOM) han revisado en este documento los principales aspectos que deben considerarse en la evaluación de los pacientes con cáncer sólido y complicaciones infecciosas. Para ello se han establecido unas recomendaciones sobre la profilaxis de las infecciones más prevalentes en estos pacientes, el uso de vacunas, las medidas de control de la infección por catéteres vasculares y la prevención de la infección ante determinadas maniobras quirúrgicas. A continuación, se han revisado los criterios de manejo de la neutropenia febril y del uso de factores estimulantes de colonias, para terminar dando una serie de pautas sobre el tratamiento del paciente oncológico con infección grave. El documento se completa con una serie de medidas para el control de la infección hospitalaria.

ABSTRACTIntroduction: Community-acquired pneumonia (CAP) is an increasing problem in the elderly that is associated with elevated morbidity and mortality. Given the expected increased life expectancy, this problem is only likely to worsen, so it has been considered that treatment effects must be examined separately in elderly adults with CAP.Areas covered: In this narrative review, we give an update of the available data of antibiotics for elderly patients with CAP. Clinical features, drug pharmacokinetics and pharmacodynamics, adverse effects, and outcomes differ in CAP depending on patient age. Older age, for example, can affect the effect of specific antibiotic regimens on important CAP clinical outcomes. Current guidelines do not offer specific recommendations for the management of CAP in elderly patients.Expert opinion: Most of our knowledge about the treatment of CAP in elderly patients has been gained from studies in young populations. However, elderly patients with CAP deserve special attention because there are several factors in this population that could influence their response to antibiotic regimens in CAP.

The influenza virus has accompanied humans since time immemorial, in the form of annual epidemics and occasional pandemics. It is a respiratory infection with multiple repercussions on people's lives at an individual and social level, as well as representing a significant burden on the health system. This Consensus Document arises from the collaboration of various Spanish scientific societies involved in influenza virus infection. The conclusions drawn are based on the highest quality evidence available in the scientific literature and, failing that, on the opinion of the experts convened. The Consensus Document addresses the clinical, microbiological, therapeutic, and preventive aspects (with respect to the prevention of transmission and in relation to vaccination) of influenza, for both adult and pediatric populations. This Consensus Document aims to help facilitate the clinical, microbiological, and preventive approach to influenza virus infection and, consequently, to reduce its important consequences on the morbidity and mortality of the population.

ABSTRACTLittle information is currently available regarding bloodstream infection (BSI) in patients with solid tumors who, for a variety of reasons, are particularly predisposed to develop this condition. In this review we focus on the incidence, epidemiology, clinical features, etiology, antimicrobial resistance, and outcomes of BSI of adult cancer patients with solid tumors. Most episodes of BSI occur in non-neutropenic patients, in whom the site of primary or metastatic tumor often serves as the portal of entry. The urinary tract and the abdomen are the most frequent sources of infection, and cholangitis is the most common recurrent source of BSI. Gram-negative bacilli are becoming the leading cause of BSI in patients with solid tumors, and the rate of multidrug resistance is increasingly being recognized. The case-fatality rate in patients with solid tumors and BSI is high, especially among those with comorbidities, advanced neoplasms, corticosteroid therapy, and shock at presentation.

We sought to determine the risk factors, molecular epidemiology, antibiotic therapy, and outcomes of bacteremia because of extensively drug-resistant (XDR) Pseudomonas aeruginosain solid organ transplant (SOT) recipients.

The portfolio has gathered pace in recent years, being a useful tool for teaching and assessment. The main goal is to improve learning through student reflection and continuous feedback of evaluations. The implantation of information technology has facilitated the introduction of the electronic portfolio (e-portfolio). Based on previous experience with portfolios, it was decided to implement it in some subjects within Medicine and Dentistry in the Department. The objectives of the study (2009-2013) have been assessing the response to its introduction, assess student satisfaction and determine the extra load imposed on the teaching process. The topic has focused on clinical skills of students, using the e-portfolio Mahara®, installed on the Virtual Campus of Barcelona University. There have been 1241 e-portfolios and 1611 email exchanges between teachers and students. All assessment is carried out on-line (average response time 48 hours, 40 minutes /portfolio). Satisfaction surveys show a high level of acceptance by the students. This allows one to conclude that the e-portfolio has proven to be a good teaching tool, presenting a high degree of compliance and satisfaction among students, encouraging student-teacher relationships.

Current information regarding bloodstream infection (BSI) in patients with solid tumors is scarce. We assessed the epidemiology, antibiotic therapy, and outcomes of BSI in these patients. We also compared patients who died with those who survived to identify risk factors associated with mortality. From January 2006 to July 2012 all episodes of BSI in patients with solid tumors at a cancer center were prospectively recorded and analyzed. A total of 528 episodes of BSI were documented in 489 patients. The most frequent neoplasms were hepatobiliary tumors (19), followed by lung cancer (18) and lower gastrointestinal malignancies (16). Many patients had received corticosteroid therapy (41), and 15 had neutropenia (<500 neutrophilsL) at the time of BSI. The most common source of BSI was cholangitis (21), followed by other abdominal (19.5) and urinary tract infections (17). Gram-negative BSI occurred in 55 of cases, mainly due to Escherichia coli(55), Pseudomonas aeruginosa(18), and Klebsiella pneumoniae(16). Among gram-positive BSI (35), viridans group streptococci were the most frequent causative organisms (22), followed by Staphylococcus aureus(21) and Enterococcusspecies (18). We identified 61 multidrug-resistant (MDR) organisms (13), mainly extended-spectrum -lactamase-producing Enterobacteriaceae (n = 20) and AmpC-producing Enterobacteriaceae (n = 13). The majority of patients with BSI caused by MDR organisms had received antibiotics (70), and they had been previously hospitalized (61.4) more frequently than patients with BSI caused by susceptible strains. Inadequate empirical antibiotic therapy was given to 23 of patients, with a higher proportion in those with BSI due to a MDR strain (69). Early (<48 h) and overall (30 d) case-fatality rates were 7 and 32, respectively. The overall case-fatality rate was higher among cases caused by MDR organisms (39.3). The only independent risk factors for the early case-fatality rate were the endogenous source of BSI (odds ratio OR, 3.57; 95 confidence interval CI, 1.06–12.02), shock at presentation (OR, 3.63; 95 CI, 1.63–8.09), and corticosteroid therapy (OR, 3.245; 95 CI, 1.43–7.32). The independent risk factors for overall case-fatality rate were the presence of a chronic advanced cancer (OR, 35.39; 95 CI, 2.48–504.91), shock at presentation (OR, 25.84; 95 CI, 3.73–179.0), and corticosteroid therapy (OR, 6.98; 95 CI, 1.61–30.21).

Community-acquired pneumonia (CAP) is an increasing problem among the elderly. Multiple factors related to ageing, such as comorbidities, nutritional status and swallowing dysfunction have been implicated in the increased incidence of CAP in the older population. Moreover, mortality in patients with CAP rises dramatically with increasing age. Streptococcus pneumoniaeis still the most common pathogen among the elderly, although CAP may also be caused by drug-resistant microorganisms and aspiration pneumonia. Furthermore, in the elderly CAP has a different clinical presentation, often lacking the typical acute symptoms observed in younger adults, due to the lower local and systemic inflammatory response. Several independent prognostic factors for mortality in the elderly have been identified, including factors related to pneumonia severity, inadequate response to infection, and low functional status. CAP scores and biomarkers have lower prognostic value in the elderly, and so there is a need to find new scales or to set new cut-off points for current scores in this population. Adherence to the current guidelines for CAP has a significant beneficial impact on clinical outcomes in elderly patients. Particular attention should also be paid to nutritional status, fluid administration, functional status, and comorbidity stabilizing therapy in this group of frail patients. This article presents an up-to-date review of the main aspects of CAP in elderly patients, including epidemiology, causative organisms, clinical features, and prognosis, and assesses key points for best practices for the management of the disease.

Although infections due to the six ESKAPE pathogens have recently been identified as a serious emerging problem, information regarding bacteremia caused by these organisms in solid-organ transplant (SOT) recipients is lacking. We sought to determine the frequency, risk factors, and outcomes of bacteremia due to drug-resistant ESKAPE (rESKAPE) organisms in liver, kidney, and heart adult transplant recipients.

Invasive fungal infection (IFI) is increasingly being recognized as a significant cause of morbidity and mortality in immunosuppressed patients. This review focuses on the latest literature reports concerning the pathogenesis of IFI in this population.

Community-acquired pneumonia (CAP) is a major public health problem all over the world. The increasing number of antibiotic-resistant bacteria is a matter of concern for physicians when choosing antibiotic treatment in patients with CAP. This review focuses on the current recommendations of antibiotic treatment, recent information concerning antibiotic resistance of pathogens, and the advances in antibiotic therapy in the field of CAP.

We performed an observational analysis of a prospective cohort of immunocompetent hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of pneumonia in patients with diabetes mellitus (DM). We also analyzed the risk factors for mortality and the impact of statins and other cardiovascular drugs on outcomes. Of 2407 CAP episodes, 516 (21.4) occurred in patients with DM; 483 (97) had type 2 diabetes, 197 (40) were on insulin treatment, and 119 (23.9) had end-organ damage related to DM. Patients with DM had different clinical features compared to the other patients. They were less likely to have acute onset, cough, purulent sputum, and pleural chest pain. No differences in etiology were found between study groups. Patients with DM had more inhospital acute metabolic complications, although the case-fatality rate was similar between the groups. Independent risk factors for mortality in patients with DM were advanced age, bacteremia, septic shock, and gram-negative pneumonia. Patients with end-organ damage related to DM had more inhospital cardiac events and a higher early case-fatality rate than did the overall population. The use of statins and other cardiovascular drugs was not associated with better CAP outcomes in patients with DM. In conclusion, CAP in patients with DM presents different clinical features compared to the features of patients without DM.

Legionella pneumophilahas been increasingly recognized as a cause of community-acquired pneumonia (CAP) and an important public health problem worldwide. We conducted the present study to assess trends in epidemiology, diagnosis, clinical features, treatment, and outcomes of sporadic community-acquired L. pneumophilapneumonia requiring hospitalization at a university hospital over a 15-year period (1995–2010). Among 3934 nonimmunosuppressed hospitalized patients with CAP, 214 (5.4) had L. pneumophilapneumonia (16 cases were categorized as travel-associated pneumonia, and 21 were part of small clusters). Since the introduction of the urinary antigen test, the diagnosis of L. pneumophilausing this method remained stable over the years (p = 0.42); however, diagnosis by means of seroconversion and culture decreased (p < 0.001 and p = 0.001, respectively).

Data on the clinical effectiveness of oseltamivir in patients with pandemic 2009 influenza A(H1N1) (A[H1N1]) virus infection are scarce. We aimed to determine the effect of timing of oseltamivir administration on outcomes in hospitalized adults with A(H1N1).

We performed an observational analysis of a prospective cohort of adults hospitalized for pandemic (H1N1) 2009 at 13 Spanish hospitals, from June to November 2009, to determine the risk factors, clinical features, and outcomes of pneumonia. Of 585 patients requiring hospitalization, chest radiography was obtained in 542. A total of 234 (43.1%) patients had pneumonia, of whom 210 underwent bacterial microbiologic studies. Of these patients, 174 (82.8%) had primary viral pneumonia and 36 (17.2%) had concomitant/secondary bacterial pneumonia. Bilateral pneumonia occurred in 48.3% of patients. Streptococcus pneumoniaewas the most frequent pathogen among patients with bacterial pneumonia (26 of 36 patients). None of them had received pneumococcal vaccine. Compared with patients without pneumonia, those with pneumonia more frequently had shock during hospitalization (9.8% vs. 1%; p < 0.001), required intensive care unit admission (22.6% vs. 5.8%; p < 0.001), underwent mechanical ventilation (17.9% vs. 3.2%; p < 0.001), and had longer length of hospital stay (median, 7 d vs. 5 d; p < 0.001). In-hospital mortality was higher in patients with pneumonia than in the others (5.2% vs. 0%; p < 0.001). Absence of comorbid conditions (odds ratio OR, 2.07; 95% confidence interval CI, 1.32-3.24) was found to be an independent risk factor for pneumonia, whereas early (≤48 h) oseltamivir therapy (OR, 0.29; 95% CI, 0.19-0.46) was a protective factor. In conclusion, pneumonia is a frequent complication among adults hospitalized for pandemic (H1N1) 2009 and causes significant morbidity. Mortality in pandemic (H1N1) 2009 is low, but occurs mainly in patients with pneumonia. Early oseltamivir therapy is a protective factor for this complication.

We performed an observational analysis of a prospective cohort of nonimmunocompromised hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of patients with liver cirrhosis. We also analyzed the prognostic value of several severity scores. Of 3420 CAP episodes, 90 occurred in patients with liver cirrhosis. The median value of the Model for End-Stage Liver Disease (MELD) was 14 (range, 6-36). On the Child-Pugh (CP) score, 56% of patients were defined as grade B and 22% as grade C. Patients with liver cirrhosis were younger (61.8 vs. 66.8 yr; p = 0.001) than patients without cirrhosis, more frequently presented impaired consciousness at admission (33% vs. 14%; p < 0.001) and septic shock (13% vs. 6%; p = 0.011), and were more commonly classified in high-risk Pneumonia Severity Index (PSI) classes (classes IV-V) (74% vs. 58%; p = 0.002). Streptococcus pneumoniae(47% vs. 33%; p = 0.009) and Pseudomonas aeruginosa(4.4% vs. 0.9%; p = 0.001) were more frequently documented in patients with cirrhosis. Bacteremia was also more common in these patients (22% vs. 13%; p = 0.023). Areas under the curve (AUCs) from disease-specific scores (MELD, CP, PSI, and CURB-65 confusion, urea, respiratory rate, blood pressure, and age ≥65 yr) were comparable in predicting severe disease (30-d mortality and intensive care unit ICU admission). A new score based on MELD, multilobar pneumonia, and septic shock at admission (MELD-CAP) had an AUC of 0.945 (95% confidence interval CI, 0.872-0.983) for predicting severe disease and was significantly different from other scores. Early (5.6% vs. 2.1%; p = 0.048) and overall (14.4% vs. 7.4%; p < 0.024) mortality rates were higher in cirrhotic patients than in patients without cirrhosis. Factors associated with mortality were impaired consciousness, multilobar pneumonia, ascites, acute renal failure, bacteremia, ICU admission, and MELD score. Among the severity scores, MELD-CAP was the only score associated with severe disease (odds ratio OR, 1.33; 95% CI, 1.09-1.52) and mortality (OR, 1.21; 95% CI, 1.03-1.42).

Legionella pneumophilais increasingly recognized as a significant cause of sporadic and epidemic community-acquired and nosocomial-acquired pneumonia. This review focuses on the latest literature concerning the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment of Legionnaires' disease.

Pneumonia developing before hospital admission in patients in close contact with the health system was recently termed ‘healthcare-associated pneumonia’ and proposed as a new category of respiratory infection. We focus on the recent literature concerning the epidemiology, causative organisms, antibiotic susceptibilities, and outcomes of and empirical antibiotic therapy for this condition.

We performed an observational analysis of pro-spectively collected data on 1,474 adult patients who were hospitalized for community-acquired pneumonia; 1,169 patients were under 80 years of age and 305 (21) patients were over 80 years (“very elderly”). Mean patient ages were 60 years in the former group and 85 years in the latter group. Severely immunosuppressed patients and nursing-home residents were not included. Comorbidities significantly associated with older age were chronic obstructive pulmonary disease, chronic heart disease, and dementia. The most common causative organism was Streptococcus pneumoniae(23 in both groups). Aspiration pneumonia was more frequent in the very elderly (5 in younger patients versus 10 in the very elderly);Legionella pneumophila(8 in younger patients versus 1 in the very elderly) and atypical agents (7 in younger patients versus 1 in the very elderly) were rarely recorded in the very elderly. While very elderly patients complained less frequently of pleuritic chest pain, headache, and myalgias, they were more likely to have absence of fever and altered mental status on admission. No significant differences were observed between groups as regards incidence of classic bacterial pneumonia syndrome (60 versus 59) in 343 patients with pneumococcal pneumonia. The development of inhospital complications (26 in younger versus 32 in very elderly patients) as well as early mortality (2 in younger versus 7 in very elderly patients) and overall mortality (6 in younger versus 15 very elderly patients) were significantly higher in very elderly patients. Acute respiratory failure and shock/multiorgan failure were the most frequent causes of death, especially of early mortality. Factors independently associated with 30-day mortality in the very elderly were altered mental status on admission (odds ratio, 3.69), shock (odds ratio, 10.69), respiratory failure (odds ratio, 3.50), renal insufficiency (odds ratio, 5.83), and Gram-negative pneumonia (odds ratio, 20.27).

Empirical antibiotic therapy of community-acquired pneumonia (CAP) has been complicated by the worldwide emergence of penicillin resistance among Streptococcus pneumoniae. The impact of this resistance on the outcome of patients hospitalized for CAP, empirically treated with betalactams, has not been evaluated in a randomized study. We conducted a prospective, randomized trial to assess the efficacy of amoxicillin-clavulanate (2 g/200 mg/8 hr) and ceftriaxone (1 g/24 hr) in a cohort of patients hospitalized for moderate-to-severe CAP. Three-hundred seventy-eight patients were randomized to receive amoxicillin-clavulanate (184 patients) or ceftriaxone (194 patients). Efficacy was assessed on Day 2, after completion of therapy and at long term follow-up. There were no significant differences in outcomes between treatment groups, both in intention-to-treat and per-protocol analysis. Overall mortality was 10.3% for amoxicillin-clavulanate and 8.8% for ceftriaxone (NS). There were 116 evaluable patients with proven pneumococcal pneumonia. Rates of high-level penicillin resistance (MIC of penicillin ≥2 µg/mL) were similar in the two groups (8.2 and 10.2%). Clinical efficacy at the end of therapy was 90.6% for amoxicillin-clavulanate and 88.9% for ceftriaxone (95% C.I. of the difference: -9.3 to +12.7%). No differences in outcomes were attributable to differences in penicillin susceptibility of pneumococcal strains. Sequential i.v./oral amoxicillin-clavulanate and parenteral ceftriaxone were equally safe and effective for the empirical treatment of acute bacterial pneumonia, including penicillin and cephalosporin-resistant pneumococcal pneumonia. The use of appropriate betalactams in patients with penumococcal pneumonia and in the overall CAP population, is reliable at the current level of resistance.

ABSTRACTThe aim of the present study was to determine the efficacy of an antibiotic-lock technique in preventing endoluminal catheter-related infection with gram-positive bacteria in neutropenic patients with hematologic malignancies. Patients with nontunneled, multilumen central venous catheters were assigned in a randomized, double-blinded manner to receive either 10 U of heparin per ml (57 patients) or 10 U of heparin per ml and 25 μg of vancomycin per ml (60 patients), which were instilled in the catheter lumen and which were allowed to dwell in the catheter lumen for 1 h every 2 days. Insertion-site and hub swabs were taken twice weekly. The primary and secondary end points of the trial were significant colonization of the catheter hub and catheter-related bacteremia, respectively. Significant colonization of the catheter hub occurred in nine (15.8%) patients receiving heparin (seven patients were colonized with Staphylococcus epidermidis, one patient was colonized with Staphylococcus capitis, and one patient was colonized withCorynebacteriumsp.), whereas the catheter hubs of none of the patients receiving heparin and vancomycin were colonized (P= 0.001). Catheter-related bacteremia developed in four (7%) patients receiving heparin (three patients had S. epidermidisbacteremia and one patient had S. capitisbacteremia), whereas none of the patients in the heparin and vancomycin group had catheter-related bacteremia (P= 0.05). The times to catheter hub colonization and to catheter-related bacteremia by the Kaplan-Meier method were longer in patients receiving heparin and vancomycin than in patients receiving heparin alone (P= 0.004 and P= 0.06, respectively). Our study shows that a solution containing heparin and vancomycin administered by using an antibiotic-lock technique effectively prevents catheter hub colonization with gram-positive bacteria and subsequent bacteremia during chemotherapy-induced neutropenia in patients with hematologic malignancy.

ABSTRACTThe in vitro activities of the ketolide telithromycin and eight other antibiotics were tested against 77 strains of viridans group streptococci isolated from blood samples of neutropenic patients. Thirty-one (40.3%) of the strains were resistant to penicillin G, and 27 (35.1%) were resistant to erythromycin A. Telithromycin (MIC range of ≤0.03 to 1 μg/ml) was the most active antimicrobial tested. These data suggest that telithromycin could be useful for treatment of viridans group streptococcal bacteremia in neutropenic patients with cancer.

Infection of long-term central venous catheters (CVCs) remains a challenge in the clinical management of cancer patients. We aimed to determine whether a lock solution with taurolidine-citrate-heparin would be more effective than placebo for preventing nontunneled CVC infection in high-risk neutropenic hematologic patients.

ABSTRACTLittle is known about the sensitivity of the BinaxNOW pneumococcal urinary antigen (PUA) test for adult pneumococcal pneumonia caused by different serotypes. In this study, we aimed to analyze the trends in the sensitivity of the PUA test over a 15-year period (2001 to 2015) and to analyze its sensitivity for pneumococcal pneumonia caused by different serotypes. In total, we analyzed 1,096 pneumococcal isolates from adults with pneumococcal pneumonia who had a PUA test performed at the onset of the episode. Three periods were analyzed: 2001 to 2005 (early use of the seven-valent pneumococcal conjugate vaccine [early PCV7]), 2006 to 2010 (late PCV7), and 2011 to 2015 (early PCV13). The sensitivity of the PUA test varied from 76.4% (95% confidence interval [CI], 70.5% to 82.4%) in the period from 2001 to 2005 to 77.9% in 2006 to 2010 (95% CI, 74.4% to 81.4%) and decreased to 60.5% (95% CI, 55.4% to 65.6%) in 2011 to 2015. This decrease was observed in 560 proven (83.2% in 2001 to 2005, 86.5% in 2006 to 2010, and 78.1%) and 536 probable (70.0% in 2001 to 2005, 68.7% in 2006 to 2010, and 41.5% in 2011 to 2015) episodes of pneumococcal pneumonia. Differences were observed in the sensitivity of the PUA test for diagnosing pneumonia caused by certain serotypes, being highest for the 9V (90.6%), 14 (86.8%), 18C (100%), and 20 (100%) serotypes and lowest for the 8 (55.2%), 9L/N (39.1%), 11A (48.8%), 23B (33.3%), and nontypeable (47.8%) serotypes. Comparing 2001 to 2005, 2006 to 2010, and 2011 to 2015, the prevalence of serotypes 9V (3.1%, 3.7%, and 1.7%, respectively) and 14 (7.2%, 5.1%, and 3.1%, respectively) decreased, while the prevalence of serotypes 23B (0%, 0.7%, and 1.4%, respectively), 9L/N (1.0%, 1.6%, and 3.4%, respectively), 11A (2.6%, 4.2%, and 3.7%, respectively), and 8 (1.5%, 1.5%, and 5.1%, respectively) increased. The PUA test sensitivity varied by pneumococcal pneumonia serotype, and these differences and the changes in serotype distribution were associated with an overall decrease in the sensitivity of the PUA test.

ABSTRACTβ-Lactam/β-lactamase inhibitors (BLBLIs) were compared to carbapenems in two cohorts of hematological neutropenic patients with extended-spectrum-β-lactamase (ESBL) bloodstream infection (BSI): the empirical therapy cohort (174 patients) and the definitive therapy cohort (251 patients). The 30-day case fatality rates and other secondary outcomes were similar in the two therapy groups of the two cohorts and also in the propensity-matched cohorts. BLBLIs might be carbapenem-sparing alternatives for the treatment of BSI due to ESBLs in these patients.

We identified 17 cases of pneumococcal bacteremia among 340 neutropenic cancer patients with bacteremia. Pneumonia was more frequent in patients with pneumococcal bacteremia than in those with bacteremia due to other organisms: 12 (71%) of 17 patients with pneumococcal bacteremia had pneumonia, whereas only 23 (7%) of 323 patients with nonpneumococcal bacteremia had pneumonia (P < .001). Eight (47%) of the 17 episodes of pneumococcal bacteremia were caused by penicillin-resistant strains (MICs ranged from 0.12 μg/mL to 4 μg/mL); these penicillin-resistant pneumococci showed varying degrees of diminished susceptibility to all 13-lactams studied, especially ceftazidime (MICs of this drug ranged from 1 μg/mL to 64 μg/mL). Imipenem was the β-lactam agent most active against these organisms (MICs ranged from 0.03 μg/mL to 0.25 μg/mL). Patients with penicillin-resistant pneumococcal bacteremia received inappropriate empirical antibiotic therapy more often than did patients with bacteremia due to susceptible strains (i.e., 4 (50%) of 8 patients vs. 0 of 9, respectively; P < .05). Eight (47%) of the 17 patients with pneumococcal bacteremia died. In areas where penicillin-resistant pneumococci are highly endemic, these findings should be considered in selecting empirical antibiotic therapy for neutropenic patients with cancer who are suspected of having pneumonia.