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The activity of daptomycin was evaluated against 702 staphylococcal blood isolates (316 methicillin-susceptible Staphylococcus aureus, 187 methicillin-resistant S. aureus [MRSA], and 199 coagulase-negative staphylococci [CoNS]) collected in 41 Spanish hospitals. Glycopeptide tolerance and the incidence of heterogeneous glycopeptide-intermediate (hGISA) isolates were also examined. Vancomycin MICs determined by the Etest were compared with those obtained by the reference broth microdilution method. Daptomycin exhibited good activity, and only 2 isolates were nonsusceptible to this antibiotic. Resistance to linezolid was observed in 2 MRSA isolates and in 16 CoNS. The cfr gene was detected in 7 of these 18 isolates. Vancomycin and teicoplanin tolerance was 9.6% and 21.9%, respectively, in MRSA isolates. We detected the hGISA phenotype in 5.8% of MRSA isolates. Vancomycin MICs by the Etest were slightly higher than those obtained by broth microdilution. Daptomycin retained activity against isolates that were not susceptible to linezolid, teicoplanin, or quinupristin-dalfopristin., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction: The objective of this study was to evaluate the activity of daptomycin and other agents against methicillin-resistant Staphylococcus aureus (MRSA) isolates collected from 2001 to 2010, in order to determine changes and to detect resistance trends., Methods: The study included a total of 1,130 MRSA isolates collected as part of a multicenter surveillance program for antibiotic resistance, Estudio de Vigilancia de Resistencia a los Antimicrobianos (VIRA study), from 51 medical centers throughout Spain between 2001 and 2010. Broth microdilution test was performed according to the Clinical Laboratory Standards Institute guidelines., Results: Daptomycin showed excellent activity and maintained its activity over time; only one MRSA isolate collected in 2001 was nonsusceptible to this agent (MIC=2 mg/L). Based on the MIC90, daptomycin was 2-4 dilutions more active than vancomycin, teicoplanin and linezolid. Daptomycin retained activity against MRSA isolates that were resistant to linezolid, to quinupristin-dalfopristin, or showed intermediate susceptibility to vancomycin., Conclusions: Our data and those of other studies, coupled with daptomycin's rapid bactericidal activity, suggest that this antimicrobial could be an alternative in the treatment of severe infections caused by multiresistant S. aureus.

Objectives: Doripenem is a new carbapenem recently introduced into Europe. The COMParative Activity of Carbapenem Testing (COMPACT) study compared the susceptibility of common Gram-negative bacilli causing serious infections in hospitalized patients with doripenem, imipenem and meropenem., Methods: Gram-negative isolates (4498 total: 2171 Pseudomonas species; 1910 Enterobacteriaceae; and 417 other Gram-negative bacilli) were collected from 80 centres in 16 countries in Europe, the Middle East and Africa during 2008-09. The MICs of doripenem, imipenem and meropenem were determined using Etest methodology and broth microdilution. Susceptibility was interpreted according to CLSI, EUCAST and FDA breakpoints., Results: The MIC(90)s of doripenem, imipenem and meropenem for all isolates were 8, ≥64 and 32 mg/L, respectively. Doripenem had the lowest MIC(90) for Pseudomonas species at 16 mg/L, with imipenem and meropenem values of ≥64 mg/L. Enterobacteriaceae were highly susceptible to all three carbapenems, with MIC(90)s of doripenem, imipenem and meropenem of 0.06, 0.5 and 0.12 mg/L, respectively. Other Gram-negative isolates, predominantly Acinetobacter baumannii, were resistant to all three carbapenems (MIC(90) ≥64 mg/L). Susceptibility to doripenem was observed in 14.9% of isolates resistant to imipenem and/or meropenem., Conclusions: Doripenem showed excellent activity against Gram-negative isolates; generally it was more active than imipenem and at least as good as meropenem. Against Pseudomonas species, doripenem was more active than both imipenem and meropenem, with doripenem susceptibility observed for some imipenem- and/or meropenem-resistant isolates.

Objective: To effectively locate the drugs most implicated in severe interactions as a basis of designing actions to improve patient safety in Primary Care., Design: Cross-sectional study of prescriptions using the Primary Care computerised medical records database (OMI-PC)., Setting: Murcia (Spain) Health Areas I, VI, VII and IX (723,664 inhabitants)., Participants: There are 362,271 patients over 14 years-old available in the OMI-PC and are assigned to a doctor who uses the OMI-PC regularly., Main Measurements: We analysed the drugs that each patient could be taking, looking for severe interactions. We constructed a severe interaction hazard scale (e-PIG) calculating [1] the probability that a non-selected patient may be taking a particular drug and [2] the probability that a drug may produce a severe interaction. With this, we estimated the risk of producing a severe interaction for each drug, which was converted into a 5 point logarithmic scale., Results: We found 83,138 patients (22.9%) at risk (they took 2 or more drugs). We identified 466,940 prescriptions providing 939 drugs and 5,597 severe interactions (prevalence 5.8%). In these, 167 drugs were involved, of which e-PIG identified 5 (3%) with an extreme value: omeprazole, diazepam, acenocoumarol, ibuprofen and calcium., Conclusions: e-PIG is a logarithmic expression of the risk that prescribing a particular drug may produce a severe interaction in a determined setting and time. Its monitoring could become a prioritisation element that may assist the design of strategies for improving the safety of the use of drugs., (Copyright © 2010 Elsevier España, S.L. All rights reserved.)

The authors tested the effectiveness and estimated the cost of several interventions aimed at reducing drug interactions in primary care by designing a 15-month cluster-controlled trial. The trial involved 265 family physicians and their patients who were randomized into 4 groups: control, report (received feedback reports), session (group sessions), and face-to-face (personal interviews). The outcome was the mean of relevant interactions detected on electronic medical records. Cost-effectiveness was defined as the incremental cost to reduce drug interactions by 1%. The authors detected a baseline mean of 6.7 interactions per 100 patients, which was reduced to 5.3 interactions after follow-up. No improvement was seen in the report group when compared with the control group, whereas progressive improvement in the other groups was noted (P < .001). Incremental cost was higher in the face-to-face group (69.4€ vs 50.7€); cost-effectiveness results were slightly better in the session group (4.2€ vs 4.5€).

We describe an outbreak of multidrug-resistant Acinetobacter baumannii producing OXA-66 carbapenemase and resistant to imipenem. We analyze the relationship between the spread of this strain and patient movements within the hospital. Thirty-one isolates of A. baumannii recovered from December 21, 2006, to February 18, 2007, were studied. Enterobacterial repetitive intergenic consensus PCR and randomly amplified polymorphic DNA genotyping methods were used to define clusters of clonally related isolates. Pulsed-field gel electrophoresis was used to confirm the results and to check the maintenance of the epidemic strain over the following year. Antibiotic susceptibility testing was performed by microdilution and E-test. The isolates were screened by PCR analysis with primers specific for carbapenemase genes. With the exception of colistin (0%) there were no antibiotics with good activity against these isolates. The epidemiology study revealed that the same strain was responsible for all the infections. This strain appeared to carry the bla(OXA-66) gene. ISAba1 was present upstream the oxacillinase gene. The clone responsible for the outbreak is still present in hospital.

Staphylococcal resistance to linezolid (LZD) is mediated through ribosomal mutations (23S rRNA or ribosomal proteins L3 and L4) or through methylation of 23S rRNA by the horizontally transferred Cfr methyltransferase. To investigate the structural basis for oxazolidinone activity against LZD-resistant (LZD(r)) strains, we compared structurally diverse, clinically relevant oxazolidinones, including LZD, radezolid (RX-1741), TR-700 (torezolid), and a set of TR-700 analogs (including novel CD-rings and various A-ring C-5 substituents), against a panel of laboratory-derived and clinical LZD(r) Staphylococcus aureus strains possessing a variety of resistance mechanisms. Potency against all strains was correlated with optimization of C- and D-rings, which interact with more highly conserved regions of the peptidyl transferase center binding site. Activity against cfr strains was retained with either hydroxymethyl or 1,2,3-triazole C-5 groups but was reduced by 2- to 8-fold in compounds with acetamide substituents. LZD, which possesses a C-5 acetamide group and lacks a D-ring substituent, demonstrated the lowest potency against all strains tested, particularly against cfr strains. These data reveal key features contributing to oxazolidinone activity and highlight structural tradeoffs between potency against susceptible strains and potency against strains with various resistance mechanisms.

Aim: To examine the detection rate of viable Mycobacterium avium subspecies paratuberculosis (MAP) in patients with inflammatory bowel disease [Crohn's disease (CD) and ulcerative colitis (UC)]., Methods: Thirty patients with CD (15 with at least one NOD2/CARD15 mutation), 29 with UC, and 10 with no inflammatory bowel disease (IBD). were tested for MAP by polymerase chain reaction (specific IS900 fragment) and blood culture., Results: MAP DNA was detected in all original blood samples and 8-wk blood cultures (CD, UC and non-IBD). Positive MAP DNA status was confirmed by dot blot assays. All 69 cultures were negative by acid-fast Ziehl-Neelsen staining. Viable MAP, in spheroplast form, was isolated from the 18-mo blood cultures of all 30 CD patients, one UC patient, and none of the non-IBD controls. No association was found between positive MAP cultures and use of immunosuppressive drugs or CD-associated single nucleotide polymorphisms., Conclusion: MAP is widely present in our area and MAP DNA can be recovered from the blood of CD, UC and non-IBD patients. However, MAP spheroplasts were only found in CD patients.

The in vitro activity of doripenem was evaluated against a recent collection of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae and Pseudomonas aeruginosa isolates (201 ESBL-producing Enterobacteriaceae [153 Escherichia coli and 48 Klebsiella pneumoniae] and 201 P. aeruginosa). Comparator agents included amikacin, tobramycin, ciprofloxacin, cefepime, cefotaxime, ceftazidime piperacillin-tazobactam, imipenem, and meropenem. Both doripenem and meropenem inhibited 100% of the ESBL-producing Enterobacteriaceae at 4 microg/mL. Doripenem is active against ESBL-producing Enterobacteriaceae and P. aeruginosa isolates. Its activity is similar to that of meropenem and slightly better than that of imipenem. The results of this study suggest that doripenem could be an alternative therapeutic agent for infections caused by these organisms.

The presence of qnr genes in 191 extended-spectrum beta-lactamase-producing Escherichia coli from 2005, with 75% of resistance to ciprofloxacin, was evaluated. An SHV-12-producing E. coli carried qnrB19; both genes were transferred by conjugation. No qnrA- or qnrS-positive strains were detected. In addition, we identified 3 new parC mutations (S80W, E84R, and E84A)., (Copyright 2010 Elsevier Inc. All rights reserved.)

The activity of ceftobiprole and comparator agents was evaluated against a collection of 880 isolates, comprising 200 meticillin-susceptible Staphylococcus aureus, 200 meticillin-resistant S. aureus, 180 coagulase-negative staphylococci blood isolates, 100 Streptococcuspneumoniae and 200 macrolide-resistant beta-haemolytic streptococci (100 Streptococcus pyogenes and 100 Streptococcus agalactiae). Ceftobiprole showed excellent activity against staphylococci (minimum inhibitory concentrations

Purpose: To investigate the prevalence and types of potential drug interactions in primary care patients to detect risky prescriptions as an essential condition to design intervention policies leading to an improvement in patient safety., Methods: Cross-sectional descriptive study., Setting: Two areas in Spain comprising 715,661 inhabitants., Patients: 430,525 subjects with electronic medical records and assigned to a family doctor regularly updating them., Results: On a random day, 29.4% of the population was taking medication. Of these, 73.9% were at risk of suffering interactions, and these were found in 20.6% of them. The amount of interactions was higher among people with chronic conditions, the elderly, females and polymedicated patients. From the total of interactions, 55.1% belonged to the highest clinical relevance 'A' level, and 28.3% should have been avoided. The active ingredients primarily involved were hydrochlorothiazide and ibuprofen and, when focusing on those that should be avoided, omeprazole and acenocoumarol. The most frequent 'A' interaction that should be avoided was between non-conjugated excreted benzodiazepines and proton-pump inhibitors, followed by some NSAIDs and diuretics., Conclusions: 1 in 20 Spanish citizens is currently undergoing a potential drug interaction, including a high rate of clinically relevant ones that should be avoided. These results confirm the existence of a serious safety issue that should be approached and where all parties involved (physicians, health services, medical societies and patients) must do our bit to improve. Health services should foster the implementation of prescription alert systems linked with electronic medical records including clinical data.

The in vitro activity of TR-700 (torezolid) was evaluated against a collection of 660 staphylococcal blood isolates. TR-700 showed excellent activity against all the staphylococci tested. The MIC(50) and MIC(90) values of TR-700, linezolid, daptomycin, and vancomycin against methicillin-resistant Staphylococcus aureus (MRSA) isolates were 0.25 and 0.5, 2 and 4, 0.5 and 0.5, and 1 and 2 microg/ml, respectively. TR-700 demonstrated greater in vitro potency than linezolid against staphylococci, including linezolid-resistant and vancomycin-nonsusceptible strains, and was 32-fold more active than linezolid against the seven cfr-positive MRSA strains tested.

Background: From April through June 2008, we identified 12 patients in the intensive care unit and 3 patients on other wards infected with methicillin-resistant Staphylococcus aureus that was also resistant to linezolid. We investigated the mechanism of resistance--point mutations in domain V of 23S ribosomal RNA (rRNA) or presence of the cfr gene--involved in the outbreak., Methods: Strains for the study were obtained in the intensive care unit and other wards. Minimal inhibitory concentrations were determined using automated methods, the E-test, or dilution in Mueller-Hinton agar in accordance with Clinical and Laboratory Standards Institute guidelines. Strains were genotyped using pulsed-field gel electrophoresis and were sequenced to determine the presence of point mutations in 23S rRNA. The presence of the cfr gene was determined by specific polymerase chain reaction., Results: The minimal inhibitory concentrations of linezolid ranged from 16 mg/L to 32 mg/L, and all the strains were susceptible to tigecycline, vancomycin, and daptomycin. Typing of strains sequentially isolated by pulsed-field gel electrophoresis showed that each patient carried only 1 clonal type of linezolid-resistant, methicillin-resistant S. aureus as detected by sequential isolations. The presence of the cfr gene was confirmed in all the isolates. Furthermore, sequencing of domain V of 23S rRNA showed that the most common mechanism of linezolid resistance reported to date, mutation G2576T, was not detected in any of the strains analyzed., Conclusions: We report the presence of the cfr gene underlying the resistance mechanism involved in a clinical outbreak of linezolid-resistant S. aureus.

Pneumotest-Latex (Statens Seruminstitut) was evaluated for direct serogrouping of Streptococcus pneumoniae strains in clinical samples from patients with invasive disease. The technique was accurate to its level of discrimination for 62 of 67 clinical samples (92.5%). Pneumotest-Latex would be a useful alternative for direct serogrouping of pneumococci in clinical samples.

Purpose: To help family doctors to detect and prevent problems related to drug-drug interactions in order to attain a higher quality prescription and an improvement in patient safety., Methods: Uncontrolled study of an intervention based on quality evaluation and improvement methods., Setting: Two health areas in Murcia Region (Spain)., Patients: Subjects appointed to 139 family doctors regularly using electronic clinical records (including doctors who were producing over 100 electronic prescriptions per week: 188,953 subjects and 334.088 prescriptions at the start, and 202,988 subjects and 335.198 prescriptions at the end of study)., Intervention: (1) A software able to collect patients who had clinically important drug-drug interactions those that should be avoided (BOT I+II) was designed. (2) A report on these interactions was drawn up and delivered periodically to every single doctor, including patient identification and information on the drugs involved, possible consequences, and recommendations about what to do. (3) Clinical and educative sessions given by a trained pharmacist were carried out in doctors' health centre coinciding with their delivery., Results: Drug-drug interactions pre-intervention: prevalence 1.29%; by patient at risk 6.57%; by doctor 20.2. Post-intervention: prevalence 1.06% (improvement 17.6%, P<.000001), by patient at risk 5.17% (improvement 21.4%, P<.000001), by doctor 17.7 (improvement 12.1, P<.001)., Conclusions: Developing this technology leads to progress in patient safety, therefore it should be extended to all our family doctors. Other technologies such as an electronic alert when prescribing should be considered, particularly for either higher frequency or important consequences interactions., (Copyright 2009 SECA. Published by Elsevier Espana. All rights reserved.)

Antimicrobial resistance and the mechanisms implicated were studied in 148 clinical Enterococcus faecium isolates with a quinupristin-dalfopristin (Q/D) MIC > or =1 microg/mL. As expected, higher levels of resistance were detected for macrolide antibiotics (94% erythromycin, 100% azithromycin, 100% josamycin). High-level resistance to gentamicin and streptomycin was detected in 18.9% and 66.2% of isolates, respectively, in our series of enterococci. Resistance against tetracycline was found in only 12.8% of the isolates, and 13 isolates were resistant to vancomycin. The dalvabancin MIC(90) for these isolates was >16 microg/mL. Polymerase chain reaction screening for the previously described streptogramin resistance determinants erm(A), erm(B), mefA/E, vat(D), and vat(E) was performed to determine the prevalence of streptogramin resistance mechanisms in these clinical enterococcal isolates. The combination of erm(B) and vat(D) genes encoding resistance to streptogramins was detected in 1 Q/D-resistant E. faecium isolate. A total of 131 Q/D-nonsusceptible enterococci only contained the erm(B) gene. The erm(B) promoter sequence reveals no differences between the strains analyzed, regardless of the Q/D MIC value.

Introduction: The objective of this study was to determine the in vitro activity of daptomycin and other agents against methicillin-resistant Staphylococcus aureus (MRSA) isolates from several sources and coagulase-negative staphylococci (CoNS) from clinically significant blood cultures., Methods: We tested a total of 1186 staphylococci isolates (755 MRSA and 431 CoNS) collected as part of a multicenter surveillance program for antimicrobial resistance (VIRA study) from 40 medical centers throughout Spain between 2001 and 2006. Broth microdilution tests were performed according to the Clinical and Laboratory Standards Institute guidelines., Results: Most MRSA isolates were resistant to ciprofloxacin (96%) and erythromycin (79.7%). Daptomycin yielded a MIC(50)/MIC(90) of 0.5/1microg/mL in MRSA, compared with 1/2microg/mL for linezolid, vancomycin, and teicoplanin. Daptomycin MICs were in the range of < or =0.125-2microg/mL. Only 1 MRSA strain had a reproducible daptomycin MIC of 2microg/mL. Among CoNS isolates, the MIC range for daptomycin was < or =0.125-1microg/mL. Daptomycin was equally active against oxacillin-susceptible and oxacillin-resistant strains., Conclusion: Daptomycin was highly active against the staphylococci isolates studied. The activity of this agent was not affected by resistance to other antibiotics such as oxacillin, teicoplanin, linezolid, ciprofloxacin, or gentamicin. These data suggest that daptomycin may be useful for the treatment of severe infection caused by MRSA or CoNS., (Copyright 2008 Elsevier España, S.L. All rights reserved.)

Animal bite wounds are common. Domestic companion animals inflict the majority of these wounds. The most important percentage of contagions are due to cat bites, and often by Pasteurella species. We present two cases of Pasteurella multocida infection after a cat bite.Thus, in this article we review the most relevant clinical features related with this aetiological agent and some aspects about antimicrobial susceptibility.

We used the broth microdilution method to determine the MICs of daptomycin and 13 comparator agents against 319 methicillin-susceptible Staphylococcus aureus isolates, 201 methicillin-resistant S. aureus (MRSA) isolates, and 183 coagulase-negative staphylococci (CoNS). Isolates were consecutively collected from bloodstream infections in 39 Spanish medical centers during a 3-month period (March through May 2008). Among MRSA, 1 isolate with intermediate susceptibility to vancomycin and 6 isolates resistant to linezolid were found. Nonsusceptibility to teicoplanin was detected in 3.9% of CoNS. Daptomycin was highly active against the staphylococcal blood isolates tested-all were inhibited at the daptomycin susceptibility breakpoint of < or = 1 microg/mL. Daptomycin retained its activity against the isolates that were resistant to teicoplanin or linezolid, or that had reduced susceptibility to vancomycin. These data suggest that daptomycin could be useful for the treatment of bloodstream infections caused by staphylococci.

Rotavirus evolves by using multiple genetic mechanisms which are an accumulation of spontaneous point mutations and reassortment events. Other mechanisms, such as cross-species transmission and inter-genotype recombination, may be also involved. One of the most interesting genotypes in the accumulation of these events is the G3 genotype. In this work, six new Spanish G3 sequences belonging to 0-2-year-old patients from Madrid were analysed and compared with 160 others of the same genotype obtained from humans and other host species to establish the evolutionary pathways of the G3 genotype. The following results were obtained: (i) there are four different lineages of the G3 genotype which have evolved in different species; (ii) Spanish G3 rotavirus sequences are most similar to the described sequences that belong to lineage I; (iii) several G3 genotype alleles were reassigned as other G genotypes; and (iv) inter-genotype recombination events in G3 viruses involving G1 and G2 were described. These findings strongly suggest multiple inter-species transmission events between different non-human mammalian species and humans.

The epidemiology of Streptococcus pneumoniae, a major cause of meningitis, pneumonia, bacteraemia and acute otitis media in both children and adults, has been altered by the availability of the seven-valent pneumococcal conjugate vaccine (PCV7) and selection pressure from broad-spectrum antibiotics. In Spain, the rates of antimicrobial consumption and resistance are high; of all S. pneumoniae isolates collected between 2001 and 2003, 9.2% were penicillin-resistant and 26.4% were penicillin-intermediate. These rates were even higher in children aged < or =4 years; 52.3% of isolates were penicillin-resistant or penicillin-intermediate. Serogroup 14 comprises nearly 9% of pneumococcal strains and exhibits the highest resistance to penicillin (69%). Since the introduction of PCV7 in Madrid, the isolates collected from hospitalized children aged <15 years from 21 hospitals revealed that only 8% of cases involving S. pneumoniae isolates were due to PCV7 serotypes, and no PCV7 vaccination failures were identified. These isolates demonstrated low rates of penicillin-non-susceptible and erythromycin-non-susceptible strains. Among multiresistant strains, serotype 19A was identified as most important. Although the recent WHO position paper on childhood immunizations speaks to the growing resistance of pneumococci, antibiotic resistance in Spain is noted to be decreasing and must be evaluated in conjunction with global studies.

Background: G9 rotavirus genotype was isolated in the 1980s and re-emerged without a clear explanation in the mid-1990s as one of the most frequently occurring genotypes with distinct genetic and molecular characteristics., Objectives: To study the G9 genotype sequence polymorphisms in Spain and compare them with the human and porcine G9 VP7 genes from the rest of the world. Complete phylogenetic analyses have been done to better characterize G9 genotypes, their relationships and evolution., Study Design: Twelve G9 VP7 genes from Spanish patients were sequenced and compared with 240 G genotype sequences. Nucleotide and amino acid sequence similarity percentages and neighbour-joining dendrograms were used to establish a new phylogenetic analysis., Results: Eight of the 12 Spanish sequenced samples had different nucleotide translated region sequences, which yielded only five different proteins. New nucleotide and amino acid sequence comparisons were made that differed from previously described results., Conclusions: Spanish G9 genotype sequences have similar structure of those belonging to lineage III as the majority of the G9 sequences and share amino acid motifs with other sequences. The phylogenetic analyses of G9 genotypes confirmed the existence of 6 lineages, but did not confirm the 11 sublineages previously reported.

Infections due to methicillin-resistant Staphylococcus aureus (MRSA) have undergone important changes in the last five years that have influenced the choice of therapy: i) increase of their frequency in hospital-associated settings and, more recently, in community settings; ii) better knowledge of clinical implications of the pharmacokinetic and pharmacodynamic properties of vancomycin; iii) improvement of current standard methods for rapid detection of MRSA in clinical samples; iv) clear evidence that vancomycin is losing efficacy against MRSA with MIC > 1 microg/mL; and v) appearance of new antibiotics suitable for use in these infections (linezolid, daptomycin, tigecyclin). Under this situation guidelines for the treatment of common infections caused by MRSA appear to be necessary to improve the efficacy and reduce the mortality.

Recent advances have made it possible to treat successfully conditions that for many years were considered incurable. In many cases, aggressive therapeutic or diagnostic techniques have been used. One resulting adverse event is a severely diminished immune response that, given the patient's situation, demands accurate and rapid treatment. Invasive fungal infection is a clear example. This review evaluates different aspects of the management of these infections.

The frequency of invasive fungal infections caused by yeasts has increased in intensive care units. The most commonly isolated species is Candida albicans, although the number of non-albicans species isolated has increased, and associated mortality is greater in patients infected with these species. The factors that most frequently predispose to invasive candidiasis in the intensive care unit are alterations in skin and mucous barriers (catheters, surgery, intubation, etc.), renal insufficiency, parenteral nutrition, and therapy with corticosteroids or broad-spectrum antimicrobials. Early diagnosis of invasive fungal infections by detecting fungal DNA or invasiveness factors, such as (1-->3)-beta-D-glucan or antimycelial antibodies, and scores to predict and empirically treat invasive candidiasis, have proven very useful in reducing associated morbidity and mortality. In recent years there have been important advances in the development of antifungal agents, especially the new azoles and candins. The efficacy and safety profile of the candins make them the best option for treating invasive candidiasis in the critically ill patient.

Introduction. As the number of multidrug-resistant strains of Pseudomonas aeruginosa has risen in the intensive care unit (ICU) of the San Carlos Clinic Hospital, 12 consecutive isolates from different patients were collected to determine the possibility of an epidemic outbreak caused by the spread of a single strain. We determined the antimicrobial susceptibility to the most common agents used in the treatment of infections caused by this bacteria. The results of susceptibility studies suggest that different strains of P. aeruginosa are responsible for the respiratory tract infections in ICU. Methods. The clonal relationship between the isolates using was determined using BOX and ERIC primers by means of repetitive sequence-based polymerase chain reaction (rep-PCR). The in vitro activity of these strains against colistin, rifampicin, doxicycline and azythromycin was studied to determine in which cases the combination of colistin with any of the other three antibiotics was synergistic. Results. Sensitivity studies point out the presence of several strains of P. aeruginosa as the causal agents of respiratory infections produced by this microorganism in the ICU. Combinations of colistin with doxycicline and colistin with azithromycin were synergistic for some isolates in the synergy studies. Discussion. Clonal studies reveal the presence of five different clones among our isolates. Therefore we can conclude that there was no outbreak of P. aeruginosa in the ICU. Synergistic activity of combinations of colistin plus azithromycin, colistin plus doxicycline and colistin plus rifampicin was less than expected and a high percentage of indifferent results was observed.

The changes in susceptibilities of Bacteroides fragilis group strains isolated in our hospital from 1997 to 2006 were studied. A total of 1,343 clinical strains were included. The study showed differences in the resistance rates in the different species of the group. Increasing resistance to clindamycin and moxifloxacin was observed. Susceptibility to imipenem, piperacillin-tazobactam, and metronidazole remained unchanged.

Objective: To analyze the process of evaluating abstracts in the 2006 National Quality in Healthcare Conference in order to contribute to its continuous improvement, and to present its main scientific results., Design: descriptive study. 11 pairs of reviewers using explicit criteria evaluated abstracts., Population: all the abstracts received., Process: abstracts were accepted/rejected according to reviewers' concordant decisions. Disagreements were re-evaluated by 3 reviewers. Accepted abstracts were organized and distributed in the Conference according to the following criteria: total amount, available room and time, number of reviewers. The abstracts nominated for awards and which did not have discrepancies higher than 25 points were re-evaluated by all the reviewers. Their presentations in the Conference were also reviewed by a panel of judges created for this purpose, according to an evaluation guide., Results: 849 communications were received. Each reviewer evaluated a mean of 79 communications, obtaining an average score of 56 points. 762 communications were accepted (89.7%), 56.8% of them as a poster. Madrid (133) and Catalonia (124) had the highest amount of presentations in the Conference, but Cantabria and Murcia obtained the highest rates per million inhabitants., Conclusions: Despite the recently introduced changes, evaluating abstracts is a complex methodological process that still can be improved. It is conditioned by the need for limiting the extension of oral presentations and Conference time management. The scientific contribution to the Conference keeps rising. Its venue represents a geographic opportunity to encourage quality works., (Copyright © 2008 Sociedad Española de Calidad Asistencial. Published by Elsevier Espana. All rights reserved.)

There is a widespread perception among Spanish pediatricians that the incidence of empyema has significantly increased in the last few years, even though the objective information available is limited, and there is no specific active epidemiological surveillance system for this condition. In the present article, we review the situation of empyema in Spain, and discuss the main hypotheses put forward in the international literature to explain this increase, as well as the limitations of the sources available. Despite the scarcity of information, we draw the following conclusions: 1) the incidence of pediatric empyema is increasing in Spain, both generally and when caused by pneumococcus in particular; 2) the reason for this increase remains unknown, and to date no firm link has been established between this phenomenon and the heptavalent conjugate pneumococcal vaccine; and 3) this situation justifies the establishment of prospective systems for the surveillance and control of empyema and, once again, highlights the importance of developing active surveillance systems for pneumococcal disease.

The Vaccine Advisory Committee of the Spanish Association of Pediatrics analyzes and discusses the criteria followed when preparing their yearly Recommended Immunization Schedule for children and adolescents. The relative importance of each criterion in the final recommendation is assessed. Following a review of the current state of affairs of childhood immunization in Spain and of the crucial role played by pediatricians, some reflections are presented on the problems derived from the vaccines recommended by this Committee but not covered by the national health system. Suggestions are made for individual pediatricians who may need to establish specific priorities in the recommendation of these vaccines.

The Vaccine Advisory Committee of the Spanish Association of Pediatrics provides information on the new developments in vaccines that have taken place in 2007, based on the available evidence, and discusses these developments. Certain modifications to the Immunization Schedule for 2008 are recommended. A second varicella vaccine booster dose, administered together with the booster dose of the measles-mumps-rubella (MMR) vaccine when children start school (3-4 years), is recommended to avoid vaccine failures against the varicella-zoster virus. Based on current scientific evidence, the importance of universal heptavalent conjugate pneumococcal vaccination, as carried out in most similar European countries and in the autonomous community of Madrid in Spain, is stressed. Human papilloma virus vaccine is included in the Immunization Schedule for girls from 11 years old, and initially, at least up to the age of 16 years. Vaccination against rotavirus in children starting at 6 weeks and completing the series before 6 months is recommended. Other recommendations included in this year's Immunization Schedule are vaccination against influenza and hepatitis A virus in risk groups and at the pediatrician's discretion, as a first step toward the future recommendation of universal immunization.

The Vaccine Advisory Committee of the Spanish Association of Pediatrics provides information on the new developments in vaccines that have taken place in 2006 and recommends certain modifications to the Immunization Schedule for 2007. To ensure early protection, the measles-mumps-rubella (MMR) vaccine booster dose should be administered when children start school (3-4 years). Based on existing scientific evidence, the importance of universal heptavalent conjugate pneumococcal vaccination, as occurs in most similar European countries and in the autonomous community of Madrid in Spain, is confirmed. The safety and efficacy of rotavirus and human papilloma virus vaccines, as well as their use in our environment, is discussed and the role of pediatricians in their implementation is stressed. The recommended immunization schedule for children and adolescents starting vaccination late is also discussed.

Introduction: The objective of this study was to determine the current antimicrobial susceptibility patterns of the most frequent multi-resistant bacteria and to analyze any possible changes with respect to the two VIRA studies carried out in 2001 and 2004., Methods: In February 2006, the 40 participating hospitals sent the following microorganisms: non-penicillin-susceptible Streptococcus pneumoniae (92), methicillin-resistant Staphylococcus aureus (MRSA) (290), clinically significant coagulase-negative staphylococci (136), ampicillin-resistant Enterococcus faecium (89), ampicillin-resistant Haemophilus influenzae (67), ciprofloxacin-resistant Escherichia coli (365), Pseudomonas aeruginosa (181), and Acinetobacter baumannii (92). The hospitals provided epidemiological data on these microorganisms. Susceptibility was determined with a broth microdilution method., Results: Among the non-penicillin-susceptible S. pneumoniae isolates, the proportion of those ones resistant to this antibiotic showed a significant (p < 0.001) decrease (59.8% in 2001, 30.2% in 2004 and 14.3% in 2006). Among MRSA, we detected one isolate nonsusceptible to linezolid, four resistant to quinupristin-dalfopristin and one strain with a vancomycin MIC of 4 microg/mL. The prevalence of extended-spectrum beta-lactamase-producing E. coli was 12.1%. Resistance of A. baumannii to imipenem varied from 27% in the 2001-2004 period to 47.8% in 2006 (p < 0.005)., Conclusion: These results again emphasize that resistance surveillance systems are an important tool for preventing the emergence and spread of multi-resistant pathogens.

The antimicrobial activity of tigecycline, a novel glycylcycline, was evaluated against 1102 bacterial isolates from 20 centers in Spain. The MIC of tigecycline at which 90% (MIC(90)) of the pneumococci tested were inhibited was the lowest (0.06 microg/mL) of all the antibiotics tested. The MICs of tigecycline against enterococci ranged from 0.03 to 0.125 microg/mL. All staphylococci were inhibited by < or =0.25 microg/mL of tigecycline, and 99.6% of Enterobacteriaceae isolates were inhibited by < or =2 microg/mL of tigecycline. Tigecycline demonstrated good activity against Bacteroides fragilis group organisms with an MIC(90) of 4 microg/mL. The results of this study confirm the excellent activity of tigecycline against multiresistant Gram-positive and Gram-negative pathogens.

Human papillomavirus (HPV) infections are the most common sexually transmitted infections in the world. This infection is a necessary cause of cervical cancer, has been related to other forms of anogenital, airway and digestive cancers, and also causes anogenital warts. The recent advances in HPV prophylactic vaccines and their imminent commercial availability will post a new challenge to pediatricians: the indication and administration of these vaccines for the prevention of HPV infection, and consequently, of cervical cancer and other HPV-related diseases. The present article reviews the essentials of HPV infection, its relationship with cervical cancer, the advances in prophylactic HPV vaccines, and the role of the pediatrician in this context.

The in vitro activity and the inoculum effect of ertapenem were evaluated against a total of 70 Enterobacteriaceae isolates resistant to extended-spectrum cephalosporins. The extended-spectrum beta-lactamase phenotypic confirmatory disk diffusion test was performed and AmpC-inducible species were detected using cefoxitin/cefotaxime disk antagonism tests. beta-Lactamases were characterised by isoelectric focusing and TEM-specific polymerase chain reaction. Minimum inhibitory concentrations (MICs) were determined by the National Committee for Clinical Laboratory Standards agar dilution method. Ertapenem showed excellent activity against almost all isolates tested, with MIC(50) and MIC(90) values of 0.03 mg/L and 0.12 mg/L, respectively. When the inoculum was increased 100-fold, susceptibility decreased from 98.6% to 65.7% for cefepime and from 75.7% to 54.3% for piperacillin/tazobactam, without changing for ertapenem. The data from this study suggest that this new carbapenem may be useful for treating mixed infections involving Enterobacteriaceae isolates resistant to third-generation cephalosporins.

During 2003 in our hospital, 236 clinical faecal Campylobacter spp. were isolated, of which 166 (70%) were resistant to tetracycline and 199 (84%) were resistant to ciprofloxacin by the disk diffusion method. Resistance to both antimicrobial agents was found in 146 isolates (62%). The in vitro activity of tigecycline was compared with that of erythromycin, clindamycin and amoxicillin/clavulanic acid using the agar dilution method against 116 selected Campylobacter spp. that were resistant to both tetracycline and ciprofloxacin. The minimum inhibitory concentration at which 90% of the isolates were inhibited (MIC90) was 0.06 mg/L for tigecycline and 4, 2 and 1 microg/mL for amoxicillin/clavulanic acid, erythromycin and clindamycin, respectively. The high in vitro activity of tigecycline against tetracycline- and ciprofloxacin-resistant strains suggests a potential therapeutic role in the treatment of infections that involve Campylobacter spp.