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The capacity of Candida spp. to form biofilms allows them to attach either to living or inert surfaces, promoting their persistence in hospital environments. In a previous study, we reported strain-to-strain variations in Candida spp. biofilm development, suggesting that some genotypes may be greater biofilm formers than others. In this study, we hypothesize that isolates pertaining to clusters may be found more frequently in the environment due to their ability to form biofilms compared to singleton genotypes. Two hundred and thirty-nine Candida spp. isolates (78 clusters) from candidemia patients admitted to 16 hospitals located in different cities and countries—and the same number of singleton genotypes used as controls—were tested in terms of biofilm formation using the crystal violet and the XTT reduction assays. Candida albicans clusters showed higher biofilm formation in comparison to singleton genotypes (P

To evaluate the course of left-sided infective endocarditis (LsIE) in patients with liver cirrhosis (LC) analyzing its influence on mortality and the impact of surgery.Prospective cohort study, conducted from 1984 to 2013 in 26 Spanish hospitals.A total of 3.136 patients with LsIE were enrolled and 308 had LC: 151 Child-Pugh A, 103 B, 34 C and 20 were excluded because of unknown stage. Mortality was significantly higher in the patients with LsIE and LC (42.5% vs. 28.4%; p0.01) and this condition was in general an independent worse factor for outcome (HR 1.51, 95% CI: 1.23-1.85; p0.001). However, patients in stage A had similar mortality to patients without cirrhosis (31.8% vs. 28.4% p = NS) and in this stage heart surgery had a protective effect (28% in operated patients vs. 60% in non-operated when it was indicated). Mortality was significantly higher in stages B (52.4%) and C (52.9%) and the prognosis was better for patients in stage B who underwent surgery immediately (mortality 50%) compared to those where surgery was delayed (58%) or not performed (74%). Only one patient in stage C underwent surgery.Patients with liver cirrhosis and infective endocarditis have a poorer prognosis only in stages B and C. Early surgery must be performed in stages A and although in selected patients in stage B when indicated.

Background The inappropriate use of antifungals is an important health problem related to increasing adverse effects, unnecessary cost and promotion of resistant and emerging fungal infections. Despite its relevance, many health institutions assign few resources to improve prescribing practices. Aims To evaluate the efficiency of an antifungal stewardship programme (ASP) centered on restricted antifungal agents. Methods The main activity during the eight-month study was to perform a programmed review of restricted antifungals (lipid formulations of amphotericin B, echinocandins and voriconazole) prescribed in hospitalized patients. In the case of amendable antifungal treatment, a recommendation was included in the electronic medical record. Results A total of 280 antifungal prescriptions for 262 patients were revised during the study period. The indications were prophylactic in 85 cases (30.4%), pre-emptive in 10 cases (3.5%), empiric in 122 cases (43.6%), and directed in 63 cases (22.5%). A total of 70 prescriptions (25%) in 61 patients were considered to be amendable. In most of these cases, treatment could have been reduced considering the patient's clinical improvement and microbiological results. The most common advice was antifungals change (70%), antifungal withdrawal (21%), removal of one antifungal drug in cases of combined therapy (7%), and switching to oral route (1%). Proposed recommendations were addressed in 28 cases (40%). There was no significant difference in adherence with respect to the type of recommendation (p = 0.554). There was a 42% lower use of antifungals during the period of the study compared to that observed during a similar previous period. Mortality among patients who were treated according to the recommendations of the ASP was 17% and in whom treatment was not modified it was 30% (p = 0.393). Conclusions ASPs centered on hospitalized patients may be an efficient strategy to ameliorate antifungal use in hospitals.

Background: There is little information concerning infective endocarditis (IE) in patients with bicuspid aortic valve (BAV) or mitral valve prolapse (MVP). Currently, IE antibiotic prophylaxis (IEAP) is not recommended for these conditions. Objectives: This study sought to describe the clinical and microbiological features of IE in patients with BAV and MVP and compare them with those of IE patients with and without IEAP indication, to determine the potential benefit of IEAP in these conditions. Methods: This analysis involved 3,208 consecutive IE patients prospectively included in the GAMES (Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España) registry at 31 Spanish hospitals. Patients were classified as high-risk IE with IEAP indication (high-risk group; n = 1,226), low- and moderate-risk IE without IEAP indication (low/moderate-risk group; n = 1,839), and IE with BAV (n = 54) or MVP (n = 89). Results: BAV and MVP patients had a higher incidence of viridans group streptococci IE than did high-risk group and low/moderate-risk group patients (35.2% and 39.3% vs. 12.1% and 15.0%, respectively; all p < 0.01). A similar pattern was seen for IE from suspected odontologic origin (14.8% and 18.0% vs. 5.8% and 6.0%; all p < 0.01). BAV and MVP patients had more intracardiac complications than did low/moderate-risk group (50% and 47.2% vs. 30.6%, both p < 0.01) patients and were similar to high-risk group patients. Conclusions: IE in patients with BAV and MVP have higher rates of viridans group streptococci IE and IE from suspected odontologic origin than in other IE patients, with a clinical profile similar to that of high-risk IE patients. Our findings suggest that BAV and MVP should be classified as high-risk IE conditions and the case for IEAP should be reconsidered. Sin financiación 18.639 JCR (2018) Q1, 3/136 Cardiac & Cardiovascular Systems 9.280 SJR (2018) Q1, 1/365 Cardiology and Cardiovascular Medicine No data IDR 2018 UEM

BACKGROUND: Fungal arthritis is usually of haematogenous origin, and mainly affects patients with impaired cellular immunity or users of intravenous drugs. The infection in immunocompetent patients is generally caused by direct inoculation of the microorganism through an invasive device. The experience of azole therapy in these patients is limited. CASE REPORT: We report a case of arthritis caused by Scedosporium apiospermum characterized by its slow onset, lack of response to posaconazole and caspofungin, and its successful resolution after surgical debridement and treatment with voriconazole. CONCLUSIONS: Treatment with voriconazole and surgical debridement is an effective therapy for arthritis due to S. apiospermum.

Cephalosporins resistance is increasing in Escherichia coli in Spain. We characterize infections by E. coli with reduced susceptibility to third-generation cephalosporins (3GCs) with the AmpC phenotype. Between January 2004 and March 2007, 121 E. coli isolates with the AmpC phenotype were collected (4.8% of all the 2538 E. coli isolates with reduced susceptibility to 3GCs). These isolates were further characterized by clinical and molecular analysis. Plasmid-encoded ampC genes were detected in 46 (38%) isolates (43 CMY-2); 75 isolates (62%) had modifications in the chromosomal ampC promoter region (c-AmpC). CMY-2 producers belonged primarily to the more virulent phylogroup D (48.4%), whereas most isolates of c-AmpC belonged to phylogroup A (56.4%). Bacteremia and infections in children were more frequently produced by CMY-2 producers. CMY-2-producing phylogroup D E. coli belonged to 8 multilocus sequence typing types. Three CMY-2 producers belonged to O25b/ST131/B2 clone. Infections caused by E. coli with the AmpC phenotype may be spreading primarily because of CMY-2-producing phylogroup D isolates, although this enzyme was also detected in the O25b/ST131/B2 clone.

OBJECTIVES: To describe trends in fosfomycin resistance in urinary isolates of Escherichia coli producing extended-spectrum beta-lactamases (ESBLs) in relation to fosfomycin consumption and to characterize representative fosfomycin-resistant isolates.METHODS: In 2007-08, an unexpected increase in fosfomycin resistance in ESBL-producing urinary E. coli was observed. Laboratory records were reviewed and a prospective surveillance study was initiated on all urinary tract infections caused by ESBL-producing, fosfomycin-resistant E. coli. bla(ESBL) types, phylogroups, genetic environment and afa/dra operon were determined by PCR and sequencing. Molecular epidemiology was analysed by PFGE and multilocus sequence typing. To elucidate possible mechanisms of fosfomycin resistance, uhpT, glpT, uhpA, ptsI, cyaA and murA genes were analysed. Fosfomycin consumption was determined as recommended by WHO.RESULTS: From 2004 to 2008, fosfomycin consumption increased by 50%, while fosfomycin resistance in ESBL producers increased from 2.2% to 21.7%. Of 26 isolates studied, 24 produced CTX-M-15 and belonged to the O25b-ST131-phylogroup B2 clonal strain. PFGE revealed two clusters. Cluster I included 18 isolates, 16 of them indistinguishable from strains producing CTX-M-15 previously described in Madrid. The five isolates of Cluster II had the IS26 linked to bla(CTX-M-15) and the afa/dra operon. In Cluster I isolates, no mutations in glpT, uhpT, uhpA, ptsI, cyaA and murA were detected. Cluster II isolates showed a 15 bp deletion (A(169)-C(183)) in uhpA.CONCLUSIONS: Fosfomycin resistance in urinary E. coli has increased due to the acquisition of this resistance by a previously circulating CTX-M-15-producing E. coli O25b-ST131-phylogroup B2 strain. This happened during a period when the use of fosfomycin increased by 50%.

INTRODUCTION Staphylococcus saprophyticus is frequent cause of urinary tract infection in women; hence, it is important to know the epidemiology and antibiotic susceptibility of this microorganism. METHOD A retrospective longitudinal study was performed in urine specimens from outpatients in our health area cultured in the Microbiology Laboratory of C.E. Arguelles (Madrid, Spain) over a 10-year period (1997-2006). RESULTS Among 35,136 urine cultures with a significant count, we identified 331 S. saprophyticus (0.9%); 324 in women and 7 in men. Mean age of the infected patients was 32.7 years. A total of 83.9% of the strains were in women aged 15 to 44 years (37 women in this group were pregnant) and the largest numbers of isolates were found during the months of June and November. All S. saprophyticus strains were susceptible to vancomycin, rifampin, gentamicin and amoxicillin-clavulanic acid. Of note, there was a high percentage of resistance to erythromycin (37.7%) (96% consistent with the MSB phenotype) which has significantly increased since 1997 (P < 0.05); 1.5% were also resistant to clindamycin. Only 0.9% were resistant to fluorquinolones. Resistance to chloramphenicol, trimethoprim/sulfamethoxazole, and penicillin was 3.9%, 6%, and 55.6%, respectively. Based on the 2006 CLSI guidelines, 45% of S. saprophyticus isolates were considered oxacillin-resistant. CONCLUSION These results suggest the following: First, S. saprophyticus should be considered among agents causing urinary tract infection in women 15 to 44 years old, including pregnant women, particularly during spring and autumn. Second, cotrimoxazole may be an excellent option for treating cystitis in patients without risk factors. Third, almost half of S. saprophyticus strains were considered oxacillin-resistant, thereby denying the benefit of treatment with oral beta-lactams in urinary tract infections. This is especially important in pregnant women, who should avoid trimethoprim/sulfamethoxazole and quinolones (FDA Group C), as well as fosfomycin, with in vitro resistance.

The aim of this study was to describe the genetic characteristics of Streptococcus pyogenes showing the MLS B phenotype of macrolide resistance from 1999 to 2005 in Spain and to highlight the substantial increase in these isolates in the last few years. The antimicrobial susceptibilities of 17,232 group A streptococci isolated from Madrid and Gipuzkoa from 1999 to 2005 were studied. The presence of the resistance genes ermA , ermB , mef , tetM , and tetO and the presence of the intTn and xis genes of the Tn 916 -Tn 1545 transposon family were studied in a sample of 739 MLS B -resistant isolates. The epidemiological relationships among these isolates were analyzed by emm typing, T typing, and multilocus sequence typing. Erythromycin resistance was found in 21.3% of the isolates analyzed (annual variation of 14.3% to 28.9%). Until 2003, most erythromycin-resistant isolates showed the M phenotype, but in 2004 and 2005, about 50% of isolates showed the MLS B phenotype. Among the MLS B -resistant isolates studied, 16 clones were identified. The most prevalent clone was a strange emm 11/T11/ST403 clone with a null yqiL allele. All but one of the 463 emm 11/T11/ST403 isolates carried the ermB , tetM , intTn , and xis genes. The second most prevalent MLS B -resistant clone was emm 28/T28/ST52, which comprised two subclones: one bacitracin-resistant, tetracycline-susceptible subclone carrying the ermB gene ( n = 115) and another bacitracin-susceptible, tetracycline-resistant subclone carrying the ermB and tetM genes ( n = 33). The rapid diffusion of these two clones, and especially of emm 11/T11/ST403, caused the large increase in MLS B -resistant S. pyogenes isolates in Spain, suggesting a potential ability for international dissemination.

BENJAMIN HERRANZa, ENRIQUE RODRIGUEZ-SALINASb Y BEATRIZ ORDENc aPediatria en Atencion Primaria. Centro de Salud Las Rozas. Madrid. Espana. bPediatria en Atencion Primaria. Centro de Salud Colmenar Viejo Norte. Madrid. Espana. cServicio de Microbiologia y Parasitologia. Centro de Especialidades Arguelles. Hospital Universitario Puerta de Hierro. Madrid. Espana. bherranz@telefonica.net; erodriguez-salinas@pap.es; beatriz.orden@gmail.com

The aim of this study was to report the emergence of linezolid-resistant coagulase-negative staphylococci (CoNS) in an intensive care unit.An observational study was conducted in critically ill patients with colonization or infection by linezolid-resistant CoNS between January 2010 and December 2014. We analyzed the epidemiological and clinical features, and the mechanism of resistance to linezolid. We also evaluated the association between the incidence of linezolid-resistant CoNS strains and the consumption of linezolid in the study period.During the study period 49 patients had a linezolid-resistant CoNS strain isolated from clinical samples (blood in 42 cases, urine in 6, peritoneal fluid in 1). Molecular study showed a combination of mechanisms of resistance. Most patients were critically ill (APACHE II score = 21.9 ± 8.3) and nearly all had undergone surgery and invasive procedures, and had prior exposure to antibiotics. Linezolid-resistant CoNS were considered to be contaminants in 42 patients and associated with infection in 7 patients, comprising bacteremia and septic shock in most of them. They were successfully treated with glycopeptides or daptomycin. A modest significant correlation was observed between the decrease in linezolid consumption and the lower incidence of resistant isolates.Linezolid-resistant CoNS had emerged in critically ill patients with severe underlying diseases and prior antibiotic exposure. Most isolates represented colonization; however, linezolid-resistant CoNS can produce serious infections in critically ill patients. Glycopeptides and daptomycin seem to provide useful alternatives for therapy of these infections. A relationship was found between linezolid consumption and the incidence of linezolid-resistant CoNS strains.

Seventy-four Streptococcus pyogenes isolates showing the macrolide–lincosamide–streptogramin B (MLS B ) resistance phenotype carrying the ermA gene (72 of which showed the inducible resistance phenotype) were obtained between 1999 and 2004. Seven different sequence types (STs) and emm types were detected: emm 22/ST46 ( n = 33); emm 77/ST63 ( n = 22); emm 73/ST331 ( n = 10); emm 94/ST89 ( n = 6); and one isolate each of emm 28/ST52, emm 11/ST403 and emm 4/ST38. All ST46 isolates were susceptible to tetracycline and almost all reacted against the T12 type (all agglutinated into the T-pattern 3/12/13/B3264). Resistance to tetracycline was observed in all ST63 ( tetO +) and ST89 ( tetM +) isolates. Most of the ST63 isolates reacted against the T28 type (all agglutinated into the T-pattern 9/13/28). The 74 isolates were grouped into eight pulsed-field gel electrophoresis pulsotypes (one cluster for each emm /ST type, except for emm 77/ST63).

A total of 151 Escherichia coli strains resistant to cefotaxime and ceftazidime were isolated during a prospective surveillance study. These strains were characterized by clinical, microbiological, and molecular analyses and were distributed into four clusters of 103, 11, 6, and 5 isolates, along with 25 unrelated strains. The principal cluster was isolated from urine, wound, blood, and other samples in three hospitals, eight nursing homes, and a community healthcare center. This cluster was associated with both nosocomial (65%) and community-acquired (35%) infections. Most strains were resistant to ciprofloxacin, gentamicin, tobramycin, cefepime, amoxicillin-clavulanic acid, and trimethoprim-sulfamethoxazole but were susceptible to imipenem. All isolates from the four clusters expressed the extended-spectrum β-lactamase (ESBL) CTX-M-15. This enzyme was also present in 8 (30.8%) of the 26 unrelated isolates. The other ESBLs, CTX-M-14 and CTX-M-32, were detected in five and seven cases, respectively, but they were detected in individual E. coli isolates only. In three clusters, bla CTX-M-15 alleles were linked to an IS Ecp1 -like element, while in eight strains of cluster II an IS 26 element preceded the bla CTX-M-15 allele. An additional pool of resistance genes included tetA , drfA14 or dfrA17 , sul1 or sul2 , aac(6′)Ib , and aac(3)IIb . All except one of the 27 isolates tested for genetic virulence markers harbored the same three virulence genes: iutA and fyuA (siderophores), and traT (serum survival factor). Epidemic or occasional isolates of cefotaxime- and ceftazidime-resistant E. coli can spread between distinct health facilities including hospitals, community health centers, and long-term care centers.

INTRODUCTION To investigate the susceptibility of group B streptococci (GBS) to macrolides and lincosamides and assess alternatives for intrapartum chemoprophylaxis in women allergic to penicillin and colonized by a GBS strain resistant to these antibiotics. METHODS Multicenter study performed with 131 strains isolated between 1997-2002 from newborns diagnosed with early-onset GBS disease and 479 strains collected in 2002 from the vagina or rectum of pregnant women. RESULTS All the GBS (100%) were susceptible to penicillin, ampicillin, vancomycin, quinupristin/dalfopristin, levofloxacin and teicoplanin. Resistance rates were as follows: 12.45% to erythromycin and azithromycin, 11.80% to clindamycin, 11.31%, to josamycin, 1.80% to telithromycin and 0.32% to fosfomycin. Seventy-nine strains had a constitutive MLSB phenotype of resistance, 4 an inducible MLSB phenotype, 3 an M phenotype and 3 were resistant to clindamycin but susceptible to macrolides. The MIC for erythromycin and azithromycin was > 32 mg/L in more than 85% of GBS strains with a constitutive MLSB phenotype, from 0.5 to 4 mg/L in those with an inducible MLSB, and 4 mg/L in those with phenotype M. Fifty-one telithromycin-sensitive strains (all with a constitutive MLSB phenotype) showed induced resistance to telithromycin when erythromycin was present. No significant differences in antimicrobial resistance were found between GBS strains producing invasive neonatal disease and maternal isolates, or among strains from different geographic areas. CONCLUSIONS The high rate of resistance to macrolides and lincosamides in our area makes susceptibility testing mandatory for GBS strains isolated from pregnant women allergic to penicillin.

Erythromycin is considered to be an adequate alternative to penicillin for patients who are allergic to penicillin. Erythromycin-resistant Streptococcus pyogenes strains have been reported in some parts of the world.The in vitro activity of erythromycin and other antimicrobial agents was determined in a total of 1310 clinical Streptococcus pyogenes isolates collected in the city of Madrid from January, 1993, through December, 1996.All strains showed susceptibility to penicillin, rifampin, vancomycin and chloramphenicol. Tetracycline resistance was 8.5%. In 36 of the strains (2.7%) MIC was 4 microg/ml for ofloxacin. Clindamycin resistance was observed in only 18 strains (1.4%); this resistance was constitutive in 15 and inducible in 3 strains. Resistance to erythromycin was observed in 14.3% of the strains, showing an increase during the study period (2.0% in 1993 vs. 22.4% in 1996; chi square for linear trend 68.8, P0,0001);90% of them showed the novel resistance phenotype described by Seppälä et al. and 32 of 32 of these strains showed by PCR the 1.4-kb fragment of the mefA gene recently described as the novel macrolide efflux resistance determinant. The erythromycin-resistant strains were isolated more often in pediatric patients (144 of 872) than in adults (44 of 438) (chi square 9.9, P = 0.0016).The study emphasizes the need to screen for resistance to macrolides in S. pyogenes and indicates that resistance to erythromycin in S. pyogenes has increased significantly in Madrid.

A 59-year-old Caucasian male presented with progressive dyspnea, arthralgias and fever for three days. A diastolic regurgitation murmur was detected in the aortic area. A transesophageal echocardiograph showed several vegetations and severe aortic regurgitation. Blood cultures yielded Neisseria gonorrhoeae beta-lactamase negative. The patient had not noticed any urogenital discomfort or urethral discharge. The patient successfully underwent surgery for septal abscess debridement. The patient received ceftriaxone 2 g bid for eight weeks and the clinical follow-up was uneventful. The review of the literature revealed a total of the 38 additional cases reported between 1980 and the present. The majority of the patients were young, male and with native valve involvement. There has been a clear tendency for left-sided valve involvement (especially in the aortic valve). All valve cultures were reported negative despite, in most cases, the marked tissue destruction. Polymerase chain reaction was performed in two patients and positive results were shown in both. Cultures of exudates from other locations were negative in most cases. One striking fact is the high proportion of patients who underwent surgery (72 %). Information regarding antibiotic sensitivity was available in 28 cases, with penicillin resistance reported in six patients (21 %) and intermediate sensitivity in four patients (14 %). Resistance to ciprofloxacin was reported in two cases (7 %). A rapid increase and distribution of isolates resistant to third generation cephalosporins have been recently detected. The mortality is high, particularly taking into account that most were young patients who had not presented previous heart disease.

Introduccion Streptococcus agalactiae es un patogeno conocido en la poblacion obstetrica y como causa de infeccion invasiva en adultos con enfermedad de base. Sin embargo, su papel en las infecciones del tracto urinario de poblacion adulta no gestante que acude a los centros de salud ha sido poco estudiado Metodos Se investigo en cinco lugares de Espana durante 6 meses el significado clinico de los aislamientos de S. agalactiae de muestras de orina procedentes de pacientes de centros de salud. Para ello se diseno un protocolo donde se incluyeron datos personales, epidemiologicos y clinicos. Se estudiaron 85 pacientes, de los cuales 79 eran mujeres (17 embarazadas) y 6 varones Resultados Se objetivo piuria en el 72,9% de los casos. El 26,4% (n = 18) de las mujeres no gestantes y los varones padecian algun tipo de enfermedad cronica de base y el 35,3% (n = 24) presentaba trastornos urinarios. En el grupo de gestantes, el 53% tenia bacteriuria asintomatica y el 35,3% colonizacion vaginal y/o uretral. En el grupo de mujeres no gestantes y varones, la entidad mas frecuente fue la cistitis no complicada, con el 66,1% (45 de 68) de los casos, despues la infeccion complicada con el 19,1% y finalmente la bacteriuria asintomatica con el 11,8%. De las 45 pacientes con diagnostico de cistitis no complicada, 35 (77,7%) tenian mas de 40 anos y 19 (42,2%) mas de 60 anos Conclusiones En los adultos no gestantes que acuden a centros de salud el aislamiento de S. agalactiae en orina significa presuntivamente en mas de la mitad de los casos infeccion urinaria no complicada, y se da sobre todo en mujeres mayores de 40 anos

OBJECTIVES: To determine the mechanisms of resistance to β-lactam antibiotics in clinical isolates of Haemophilus parainfluenzae.METHODS: Twenty clinical isolates of H. parainfluenzae with decreased susceptibility to aminopenicillins were examined and compared with a control group of 20 fully susceptible isolates. In this collection, the presence of amino acid substitutions in the transpeptidase domain of penicillin-binding protein 3 (PBP3), β-lactamase production and the surrounding genetic regions of blaTEM genes in selected isolates were analysed.RESULTS: Of the 20 non-susceptible isolates, 8 produced TEM β-lactamase (gBLPAR), 7 had mutations in the transpeptidase domain of the ftsI gene related to decreased susceptibility to β-lactams (gBLNAR) and 5 had both resistance mechanisms (gBLPACR). No resistance mechanisms were identified in the susceptible control group (gBLNAS). gBLNAR isolates had MIC90 values 4- to 16-fold higher than gBLNAS isolates for ampicillin, amoxicillin/clavulanic acid, cefuroxime, cefotaxime and cefixime, and the most common PBP3 mutation was Asn526Ser. The additional Ser385Thr substitution (III-like group) may confer decreased susceptibility to cefotaxime, cefixime and aztreonam, as in Haemophilus influenzae. In two β-lactamase-positive isolates without PBP3 mutations, the inhibitor-resistant TEM (IRT) β-lactamases TEM-34 and the novel TEM-182 were detected and carried by a TnA transposon of the Tn2 type; both isolates had an amoxicillin/clavulanic acid MIC of ≥8 mg/L. The TnA transposons of two β-lactamase-positive isolates (TEM-1 and TEM-182) were inserted between the tfc20 and tfc21 genes, typically associated with integrative and conjugative elements in Haemophilus spp.; the TEM-34 IRT β-lactamase was harboured in a ∼5.5 kb plasmid.CONCLUSIONS: Clinical isolates of H. parainfluenzae express a variety of aminopenicillin resistance mechanisms, either alone or in combination, including PBP3 modifications, blaTEM-1 and IRT β-lactamase production.

Neisseria meningitidis is an uncommon cause of acute bacterial conjunctivitis. One case of primary meningococcal conjunctivitis in a healthy 6-year-old boy is reported. The patient was initially treated with a topical instillation of polymyxin B, neomycin and gramicidin in ophthalmic solution, and this was followed by systemic rifampin once the diagnosis had been established. No ocular or systemic complications developed.

To evaluate the Sysmex UF-1000i system as a urine screening method for the diagnosis of urinary tract infection, and epithelial cells as a predictive value of contamination in woman of childbearing age.A total of 1730 urine samples were processed using a urine culture as a reference.With 50 bacteria/μl as a cut-off point, the results were: sensitivity 91.3%, specificity 73.1%, negative predictive value 96.2%. For a specificity of 90% for epithelial cells, the results were: sensitivity 31.0%, positive predictive value 67.0%, negative predictive value 66.0%.The evaluated system is fast and effective. Epithelial cells could be used to predict contamination.

Fungal arthritis is usually of haematogenous origin, and mainly affects patients with impaired cellular immunity or users of intravenous drugs. The infection in immunocompetent patients is generally caused by direct inoculation of the microorganism through an invasive device. The experience of azole therapy in these patients is limited.We report a case of arthritis caused by Scedosporium apiospermum characterized by its slow onset, lack of response to posaconazole and caspofungin, and its successful resolution after surgical debridement and treatment with voriconazole.Treatment with voriconazole and surgical debridement is an effective therapy for arthritis due to S. apiospermum.

The aim of this study was to determine the prevalence and characteristics of non-fluoroquinolone (FQ)-susceptible Streptococcus pyogenes isolates and to study their mechanisms of resistance. We performed a prospective prevalence study with 468 isolates collected from 2005 to 2007 and a retrospective study that was based on the examination of existing data collected from 1999 to 2008. The retrospective study included data for isolates with high-level resistance (HR) to ciprofloxacin (MIC ≥ 32 μg/ml) (HR isolates) and isolates with the same emm types as those reported in the literature with low-level resistance (LR) to ciprofloxacin (MICs, 2 to 8 μg/ml) (LR isolates, n = 205). Genetic characterization of the isolates was performed by means of emm typing and multilocus sequence typing. The prevalence of LR ranged from 1.9% in 2005 to 30.8% in 2007. This increase was mainly due to the circulation of an emm 6 subtype ( emm 6.4) that represented 77.1% of the LR isolates in 2007. Notably, another emm 6 subtype, also detected in 2007 ( emm 6.37), showed coresistance to 14- and 15-membered macrolides mediated by the mefA gene. Only three HR isolates were detected (isolates emm 68.1/ST247/T3,13,B3264, emm 77/ST399/T28, and emm 28/ST52/T28), and all were identified in the retrospective study. Overall, the 673 isolates represented 25 emm types. All LR isolates were clustered into two emm types: emm 6 (six emm 6 subtypes) and emm 75. All the 156 emm 6 isolates had LR, harbored the Ser79/Ala mutation in the parC gene product, and had the same sequence type (ST), ST382. Most (21/33) of the emm 75 isolates had LR, showed the Ser79/Phe plus Asp91/Asn double mutation in the parC gene product, and were ST150. The Asp91/Asn mutation by itself did not confer resistance to FQs.

Staphylococcus saprophyticus is frequent cause of urinary tract infection in women; hence, it is important to know the epidemiology and antibiotic susceptibility of this microorganism.A retrospective longitudinal study was performed in urine specimens from outpatients in our health area cultured in the Microbiology Laboratory of C.E. Argüelles (Madrid, Spain) over a 10-year period (1997-2006).Among 35,136 urine cultures with a significant count, we identified 331 S. saprophyticus (0.9%); 324 in women and 7 in men. Mean age of the infected patients was 32.7 years. A total of 83.9% of the strains were in women aged 15 to 44 years (37 women in this group were pregnant) and the largest numbers of isolates were found during the months of June and November. All S. saprophyticus strains were susceptible to vancomycin, rifampin, gentamicin and amoxicillin-clavulanic acid. Of note, there was a high percentage of resistance to erythromycin (37.7%) (96% consistent with the MSB phenotype) which has significantly increased since 1997 (P0.05); 1.5% were also resistant to clindamycin. Only 0.9% were resistant to fluorquinolones. Resistance to chloramphenicol, trimethoprim/sulfamethoxazole, and penicillin was 3.9%, 6%, and 55.6%, respectively. Based on the 2006 CLSI guidelines, 45% of S. saprophyticus isolates were considered oxacillin-resistant.These results suggest the following: First, S. saprophyticus should be considered among agents causing urinary tract infection in women 15 to 44 years old, including pregnant women, particularly during spring and autumn. Second, cotrimoxazole may be an excellent option for treating cystitis in patients without risk factors. Third, almost half of S. saprophyticus strains were considered oxacillin-resistant, thereby denying the benefit of treatment with oral beta-lactams in urinary tract infections. This is especially important in pregnant women, who should avoid trimethoprim/sulfamethoxazole and quinolones (FDA Group C), as well as fosfomycin, with in vitro resistance.

Streptococcus agalactiae is a well-recognized pathogen in the obstetric population and is a cause of invasive infection in adults with underlying diseases. Nevertheless, the role of S. agalactiae in urinary tract infections in the adult non-pregnant population treated in outpatient health care centers has been less extensively studied.The clinical significance of S. agalactiae isolation in urine samples from health care center patients was studied in five areas of Spain over a period of six months. The study protocol included the collection of personal, epidemiological and clinical data. A total of 85 patients were studied; 79 were women (17 pregnant) and 6 men.Pyuria was found in 72.9% of the cases. A total of 26.4% (n = 18) of non-pregnant women and all the men had some type of chronic underlying disease and 35.3% (n = 24) had urinary disease. Among the pregnant women, 53% had asymptomatic bacteriuria and 35.3% had vaginal and/or urethral colonization. Among the group of men and non-pregnant women, the most frequent entity was non-complicated cystitis, seen in 66.1% (45 of 68) of cases, followed by complicated infection in 19.1% and asymptomatic bacteriuria in 11.8%. Of the 45 patients with non-complicated cystitis, 35 (77.7%) were over 40 years old and 19 (42.2%) were over 60 years old.Among the population of non-pregnant adults treated in outpatient health care centers, S. agalactiae isolation from urine was found mainly in women over 40 years old and was the cause of non-complicated urinary tract infection in more than half of cases.

In Spain, the frequency of resistance of group A streptococci (GAS) to erythromycin was very low, increasing from 0 to 0.7% in 1989 and 1990 (1, 7) to approximately 3% in 1991 to 1994 (2). The purpose of the present study was to determine the susceptibilities of recent isolates of GAS to macrolides and, in the case of resistant isolates, to ascertain their patterns of erythromycin resistance. We also studied the in vitro activities of penicillin G and clindamycin. A total of 222 isolates of GAS were collected from April to August 1996 from outpatient samples in Madrid, Spain. A total of 203 isolates were throat swab samples and 19 were from other sources. Identification was done by biochemical tests according to standard criteria (8). Penicillin G, erythromycin, azithromycin, miocamycin, and clindamycin were tested. The MICs were determined by the agar dilution method with Mueller-Hinton agar supplemented with 5% defibrinated horse blood. The plates were incubated overnight at 35°C in a 5% carbon dioxide atmosphere. The procedures for susceptibility testing were those recommended by the National Committee for Clinical Laboratory Standards (6). The MIC breakpoint for miocamycin resistance was >4 μg/ml, as defined by the Comite de l’Antibiogramme de la Societe Francaise de Microbiologie (10). Erythromycin resistance was classified according to the results of disk diffusion, with a double-disk test with erythromycin and clindamycin disks, as previously described (9), to test for inducible resistance. The MIC ranges and the MICs at which 50 and 90% of isolates were inhibited (MIC50s and MIC90s, respectively) for the 222 isolates of Streptococcus pyogenes are given in Table ​Table1.1. Penicillin remained exquisitely active, with an MIC90 of 0.03 μg/ml. TABLE 1 In vitro susceptibilities of 222 recent GAS strains to five antimicrobial agents Thirty-nine (17.6%) of the isolates tested were resistant to erythromycin (MIC breakpoint, ≥1 μg/ml). In contrast, only 0.5% of the S. pyogenes isolates were resistant to clindamycin (MIC90, ≤0.12 μg/ml). The resistance to both 14- and 15-membered macrolides tested was 17.6%, whereas the resistance to miocamycin, a 16-membered macrolide, was 0.5%. Thirty-seven (95%) of 39 erythromycin-resistant GAS were susceptible to clindamycin (MICs, ≤0.12 μg/ml) and miocamycin (MICs, 0.5 to 1 μg/ml). One isolate was resistant to erythromycin (MIC, >64 μg/ml), azithromycin (MIC, >16 μg/ml), miocamycin (MIC, >64 μg/ml), and clindamycin (MIC, >64 μg/ml), which indicates cross-resistance to macrolides, lincosamides, and streptogramin B-type antibiotics (MLSB phenotype). Another erythromycin-resistant strain was susceptible to clindamycin but showed an inducible type of erythromycin resistance. All erythromycin-resistant isolates were also resistant to the 15-membered macrolide azithromycin. However, the 16-membered macrolide miocamycin showed good activity against these isolates. The MICs for 37 of 39 erythromycin-resistant isolates were moderate (8 to 32 μg/ml), but the MICs of clindamycin were the same as those for the erythromycin-susceptible isolates (≤0.12 μg/ml); this pattern has been described with the M phenotype (11) and “novel resistance” (9). With this phenotype, susceptibility to clindamycin and streptogramin B antibiotics but resistance to 14- and 15-membered macrolides is seen (11). The mechanism of erythromycin resistance involves active efflux. The rate of isolation of strains with this novel phenotype among the erythromycin-resistant GAS of our work is even higher than that recently reported in the United States (75%) (11), although the incidence of erythromycin-resistant GAS is rare in this country (3). However, 50% of erythromycin-resistant GAS isolated in Japan (5) and in Taiwan (4) were also resistant to clindamycin and tetracycline. In conclusion, our report documents the emergence of high rates of resistance to erythromycin in S. pyogenes in Spain. Strains with the M phenotype account for the majority of those isolates, which in a sample of this size represents a significant finding. Clindamycin remained active against these strains and might be useful for treatment of patients with clinical failure after phenoxymethyl penicillin treatment and for penicillin-allergic patients. We suggest that clinical laboratories review their local susceptibility data. If erythromycin resistance rates are high, we recommend that susceptibilities to both macrolides and clindamycin in S. pyogenes isolates be routinely tested.

Presentamos el caso de un paciente de sexo masculino de 45 anos de edad, diagnosticado de mastocitosis cutanea desde el primer ano de vida y de liquen plano erosivo de mucosas y hepatitis C cronica en el ano 1990. Preciso tratamiento en los ultimos anos con corticoides orales, azatioprina, interferon y ribavirina. En la actualidad estaba en tratamiento con cloroquina. Acudio a la consulta de Dermatologia por notar la aparicion, un mes antes, de una macula blanquecina en la superficie de la una del dedo gordo del pie derecho. La mancha se habia extendido hasta afectar toda la superficie ungueal y era totalmente asintomatica. A la exploracion se observaba una lamina ungueal blanco-amarillenta homogenea y de superficie lisa (fig. 1). No presentaba signos de paroniquia asociada. Se procedio a la toma de una muestra para cultivo micologico. Al raspar la una, la superficie ungueal se desmenuzo, arrastrandose la parte afectada de la una hasta casi eliminarla (fig.2). Se efectuo cultivo del material obtenido en agar glucosado de Sabouraud con y sin actidiona. En la placa sin actidiona crecieron colonias blancas algodonosas, mientras que en la placa con actidiona no hubo crecimiento. Se realizo subcultivo en agar glucosado con patata donde desarrollo una coloracion violeta (fig. 3). En la observacion microscopica con azul de lactofenol por el metodo de la cinta adhesiva se apreciaron microconidias ovaladas y macroconidias multicelulares en forma de platano.

Vulvovaginitis is the most common gynaecological problem in prepubertal girls and clear-cut data on the microbial aetiology of moderate to severe infections are lacking. Many microorganisms have been reported in several studies, but frequently the paediatrician does not know the pathogenic significance of an isolate reported in vaginal specimens of girls with vulvovaginitis. A multicentre study was performed, selecting 74 girls aged 2 to 12 years old with a clinical picture of vulvovaginitis and inflammatory cells on Gram stain. All the specimens were cultured following standard microbiological techniques and the paediatricians completed a questionnaire to highlight risk factors after interviewing the parents or tutors. The data were compared with those obtained in a control group of 11 girls without vulvovaginitis attending a clinic. Streptococcus pyogenes and Haemophilus spp.were isolated in 47 and 12 cases, respectively. Upper respiratory infection in the previous month ( P