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Introduction Continuous antimicrobial resistance surveillance is recommended by Public Health authorities. We updated data from the SMART (Study for Monitoring Antimicrobial Resistance Trends) surveillance study in Spain. Material and methods The antimicrobial susceptibility data and extended-spectrum beta-lactamase (ESBL) production in isolates recovered from intra-abdominal (IAI) (n=1,429) and urinary tract (UTI) (n=937) infections during the 2016-2017 SMART study in 10 Spanish hospitals were analysed. Results Escherichia coli was the most frequently microorganism isolated (48.3% and 53.7%) followed by Klebsiella spp. (11.5% and 21.9%) in IAIs and UTIs, respectively. Figures for Pseudomonas aeruginosa were 9.0% and 6.1%, being more frequently recovered from patients with nosocomial infections. Overall, 9.9% (IAI) and 14.0% (UTI) of E. coli, Klebsiella spp. and Proteus mirabilis isolates were ESBL-producers, being Klebsiella pneumoniae (34.5%) from UTI of nosocomial origin the most frequent. ESBL-producers were higher in patients >60 years in both IAIs and UTIs. As in previous years, amikacin (96.3%-100% susceptibility), ertapenem (84.2%-100%) and imipenem (70.3%-100%) were the most active antimicrobials tested among Enterobacterales species. The activity of amoxicillin-clavulanic, piperacillin-tazobactam, and ciprofloxacin susceptibility was lower, particularly among ESBL-producers. Ertapenem susceptibility (88.9%-100%) was retained in ESBL-E. coli isolates that were resistant to these antimicrobials but decreased (28.6%-100%) in similar isolates of K. pneumoniae. Conclusions Continuous antimicrobial resistance surveillance from the SMART study reveals overall maintenance of ESBL-producers in Spain, although with higher presence in isolates from UTIs than from IAIs. Moreover, ertapenem activity was high in E. coli irrespective of ESBL production but decreased in K. pneumoniae, particularly among ESBL-producers.

Статья посвящена проблеме инклюзивного образования. По мнению авторов, в каждом образовательном учреждении должны быть созданы условия для получения качественного образования без дискриминации лицами с ограниченными возможностями здоровья, для коррекции нарушений развития и социальной адаптации, оказания ранней коррекционной помощи на основе специальных педагогических подходов и наиболее подходящих для этих лиц языков, методов и способов общения, а также социальному развитию этих лиц, в том числе посредством инклюзивного образования лиц с ограниченными возможностями здоровья.

espanolObjetivo. Analizar la sensibilidad a ceftolozano-tazobactam y antimicrobianos comparadores en Enterobacterales y Pseudomonas aeruginosa procedentes de infecciones intraabdominales (IIA), urinarias (ITU) y respiratorias (ITR) y bacteriemias del estudio SMART (Study for Monitoring Antimicrobial Resistance Trends). Metodos. Se analizo (EUCAST-2020) la sensibilidad de 5.351 aislados recogidos en 11 hospitales espanoles (2016- 2018) mediante microdilucion en caldo y se estudio fenotipicamente la presencia de betalactamasas de espectro extendido (BLEE). En aislados resistentes a ceftolozano-tazobactam y/o carbapenemicos se caracterizaron las BLEE y carbapenemasas. Resultados. Escherichia coli fue el patogeno mas frecuente (49,3% IIA, 54,9% ITU, 16,7% ITR y 50% bacteriemia), seguido de Klebsiella pneumoniae (11,9%, 19,1%, 13,1% y 15,4%, respectivamente). P. aeruginosa se aislo en el 9,3%, 5,6%, 32% y 9%, respectivamente. La frecuencia de aislados con BLEE (2016-2017) fue: 30,5% K. pneumoniae, 8,6% E. coli, 2,3% Klebsiella oxytoca y 0,7% Proteus mirabilis. Ceftolozanotazobactam fue muy activo en E. coli no productor (sensibilidad 99,3%) y productor de BLEE (95,2%) y menos activo en K. pneumoniae (98% y 43,1%, respectivamente). CTX-M-15 fue la BLEE mas prevalente en E. coli (27,5%) y K. pneumoniae (51,9%) frecuentemente asociada con OXA-48-like. Un 93% de los aislados de P. aeruginosa fueron sensibles a ceftolozanotazobactam, que mantuvo su actividad (>75%) en aislados resistentes a otros betalactamicos excepto en los resistentes a meropenen o ceftazidima-avibactam. GES-5, PER-1, VIM-1/2 fueron las enzimas mas prevalentes en aislados resistentes a ceftolozano-tazobactam. Conclusiones. Ceftolozano-tazobactam mostro elevada sensibilidad frente a los aislados del estudio SMART, aunque disminuyo en K. pneumoniae y P. aeruginosa con BLEE y/o carbapenemasas. EnglishObjective. To analyse the susceptibility to ceftolozane-tazobactam and comparators in Enterobacterales and Pseudomonas aeruginosa isolates recovered from intraabdominal (IAI), urinary (UTI), respiratory (RTI) and bloodstream infection (BSI) in the SMART (Study for Monitoring Antimicrobial Resistance Trends) study. Methods. The susceptibility of 5,351 isolates collected in 11 Spanish hospitals (2016-2018) were analysed (EUCAST-2020 criteria) by broth microdilution and were phenotypically studied for the presence of extended-spectrum beta-lactamases (ESBL). Ceftolozane-tazobactam and/or carbapenem resistant isolates were genetically characterized for ESBL and carbapenemases. Results. Escherichia coli was the most frequent pathogen (49.3% IAI, 54.9% UTI, 16.7% RTI and 50% BSI), followed by Klebsiella pneumoniae (11.9%, 19.1%, 13.1% and 15.4%, respectively). P. aeruginosa was isolated in 9.3%, 5.6%, 32% and 9%, respectively. The frequency of isolates with ESBLs (2016- 2017) was: 30.5% K. pneumoniae, 8.6% E. coli, 2.3% Klebsiella oxytoca and 0.7% Proteus mirabilis. Ceftolozane-tazobactam was very active against non-ESBL-(99.3% susceptible) and ESBL-(95.2%) producing E. coli being less active against K. pneumoniae (98% and 43.1%, respectively) isolates. CTX-M-15 was the most prevalent ESBL in E. coli (27.5%) and K. pneumoniae (51.9%) frequently associated with OXA-48-like carbapenemase. Overall, 93% of P. aeruginosa isolates were susceptible to ceftolozane-tazobactam, preserving this activity (>75%) in isolates resistant to other beta-lactams except in those resistant to meropenen or ceftazidime-avibactam. GES-5, PER-1, VIM-1/2 were the most prevalent enzymes in isolates resistant to ceftolozane-tazobactam. Conclusions. Ceftolozane-tazobactam showed high activity rates against isolates recovered in the SMART study although it was affected in K. pneumoniae and P. aeruginosa isolates with ESBL and/or carbapenemases.

Escherichia coli is overrepresented in all bloodstream infections (BSIs) series, mostly associated with a few clonal lineages. Its population structure has been analyzed but the dynamics remains to be fully understood. We analyze the dynamics of E. coli-BSIs in a sample of 649 isolates, representing all 7165 E. coli BSI episodes recorded in a tertiary hospital (1996-2016) according to clonal identification (phylogenetic groups/subgroups, STc131 subclades), antibiotic susceptibility (13 antibiotics), and virulence-associated genes (VAGs, 29 genes). Patient data were obtained from the laboratory system and clinical charts. The incidence of BSI-EC doubled from 1996 to 2016 (5.5 to 10.8 BSI episodes/1000 hospitalizations). Intertwined waves of community-acquired (CA) and hospital-acquired isolates (HA) episodes of both B2 and non-B2 phylogroups, occurred until B2 overtook non-B2 BSI episodes. ST131 contributed to increasing the B2 rates, but only transiently altered the population structure. B2 isolates predominates (53%), overrepresented by subgroups B2-I (STc131), B2-II, B2-IX, and B2-VI (25%, 25%, 14%, and 9%). We observed a remarkable increase only for B2-I-STc131 (C1/C2 subclades), a decreasing trend for phylogroup D, and oscillations for other B2 subgroups throughout the years. According to VAG patterns, B2 strains exhibit a population structure compatible with the niche specialization theory. A reservoir of B2 and non-B2 strains represented in human microbiota, flows from the community to the hospital and vice-versa, where they can either be selected or coexist. The increase of BSI is determined by waves of CA that predate the amplification of HA episodes of both B2 and non-B2 phylogroups in various time periods, influenced by FQR and microbiota composition. IMPORTANCE The gut microbiota is an important reservoir for bacteria that cause extraintestinal infections including sepsis, which is the third cause of mortality in Western countries and one of the Global Health threads recognized by the WHO since 2017. Most of the bloodstream infections (BSI) and UTIs due to Escherichia coli strains originate in the gut microbiota and belong to the phylogenetic group B2. Most B2 strains recovered from BSI infections are clonal lineages predominant in fecal isolates, often associated with outbreaks. Our study analyzes the long-term dynamics of B2 E. coli subtypes and reveals waves of different E . coli lineages including pandemic clones that emerge periodically and are established in the intestinal microbiota afterward. It also reflects that clonal amplifications in the community predates the clonal increases in hospitals which may favor the acquisition of antibiotic resistance in health centers and further dissemination of well adapted clones that become multidrug resistant.

SMART-Spain Working Group., [Objective] The SMART (Study for Monitoring Antimicrobial Resistance Trends) surveillance study monitors antimicrobial susceptibility and extended spectrum β-lactamases (ESBLs) in Gram-negative bacilli recovered from intra-abdominal infections (IAI)., [Methods] Antimicrobial susceptibility of 5,343 isolates from IAI recovered in 11 centres during the 2011-2015 SMART-Spain program was analysed by standard microdilution (EUCAST criteria) and compared with that from 2002-2010. ESBLs were phenotypically detected., [Results] Escherichia coli, the most common isolate, significantly decreased in community acquired IAI (60.9% 2002-2010 vs. 56.1% 2011-2015, P=0.0003). It was followed in prevalence by Klebsiella pneumoniae that increased both in the community (8.9% vs. 10.8%, P=0.016) and nosocomial (9.2% vs. 10.8%, P=0.029) IAI and P. aeruginosa, which significantly increased in community acquired IAI (5.6% vs. 8.0%, P=0.0003). ESBLs were more prevalent in K. pneumoniae (16.3%) than in E. coli (9.5%) of nosocomial origin and were more frequently isolated from elderly patients (>60 years). Considering all Enterobacteriaceae, ertapenem (92.3-100%) and amikacin (95.5%-100%) were the most active antimicrobials. Ertapenem activity, unlike amoxicillin-clavulanate or piperacillin-tazobactam, remained virtually unchanged in ESBL (100%) and non-ESBL (98.8%) E. coli producers. Its activity decreased in ESBL-K. pneumoniae (74.7%) but was higher than that of amoxicillin-clavulanate (14.0%) and piperacillin-tazobactam (24.0%). Interestingly, ertapenem susceptibility was maintained in >60% of ESBL isolates that were resistant to amoxicillin-clavulanate, piperacillin-tazobactam or fluoroquinolones., [Conclusions] SMART-Spain results support current guidelines which include ertapenem as empiric treatment in mild-moderate community-acquired IAI, particularly with ESBL producers. These recommendations will need to be updated with the recently introduction of new antimicrobials., [Introducción] El estudio SMART (Study for Monitoring Antimicrobial Resistance Trends) monitoriza la sensibilidad antimicrobiana y las β-lactamasas de espectro extendido (BLEE) en bacilos gramnegativos obtenidos de infecciones intraabdominales (IIA)., [Material y Métodos] Se ha analizado la sensibilidad antimicrobiana (microdilución estándar, criterios EUCAST) y las BLEE (detección fenotípica) de 5.343 aislados de IIA en 11 centros del programa SMART-España durante 2011-2015 en comparación con 2002-2010., [Resultados] Escherichia coli, el microorganismo más prevalente, disminuyó significativamente en las IIA de origen comunitario (60,9% 2002-2010 vs. 56,1% 2011-2015, P=0,0003). Fue seguido en prevalencia por Klebsiella pneumoniae que aumentó tanto en IIA comunitaria (8,9% vs. 10,8%, P=0,016) como nosocomial (9,2% vs. 10,8%, P=0,029) y por P. aeruginosa que aumentó en la IIA comunitaria (5,6% vs. 8,0%, P=0,0003). Las BLEE fueron más prevalentes en la IIA nosocomial por K. pneumoniae (16,3%) que por E. coli (9,5%), siendo más frecuentes en pacientes de mayor edad (>60 años). Considerando todas las Enterobacteriaceae, ertapenem (92,3-100%) y amikacina (95,5%-100%) fueron los antimicrobianos más activos. La sensibilidad a ertapenem, al contrario que a amoxicilina-clavulánico o piperacilina-tazobactam, se mantuvo sin cambios en E. coli con (98,8%) y sin BLEE (100%). Su sensibilidad disminuyó en BLEE-K. pneumoniae(74,7%) pero fue mayor que la de amoxicilina-clavulánico (14,0%) o piperacilina-tazobactam (24,0%). Es de resaltar que esta actividad se mantuvo >60% en los aislados con BLEE resistentes a amoxicilina-clavulánico, piperacilina-tazobactam o fluoroquinolonas., [Conclusiones+ El estudio SMART-España sustenta las guías actuales que incluyen al ertapenem como tratamiento empírico en la IIA leve-moderada comunitaria, en particular con BLEE. Estas recomendaciones precisaran actualizarse con la reciente introducción de nuevos antimicrobianos.

Objective: The SMART (Study for Monitoring Antimicrobial Resistance Trends) surveillance study monitors antimicrobial susceptibility and extended spectrum β-lactamases (ESBLs) in Gram-negative bacilli recovered from intra-abdominal infections (IAI). Methods: Antimicrobial susceptibility of 5,343 isolates from IAI recovered in 11 centres during the 2011-2015 SMART-Spain program was analysed by standard microdilution (EUCAST criteria) and compared with that from 2002-2010. ESBLs were phenotypically detected. Results: Escherichia coli, the most common isolate, significantly decreased in community acquired IAI (60.9% 2002-2010 vs. 56.1% 2011-2015, P=0.0003). It was followed in prevalence by Klebsiella pneumoniae that increased both in the community (8.9% vs. 10.8%, P=0.016) and nosocomial (9.2% vs. 10.8%, P=0.029) IAI and P. aeruginosa, which significantly increased in community acquired IAI (5.6% vs. 8.0%, P=0.0003). ESBLs were more prevalent in K. pneumoniae (16.3%) than in E. coli (9.5%) of nosocomial origin and were more frequently isolated from elderly patients (>60 years). Considering all Enterobacteriaceae, ertapenem (92.3-100%) and amikacin (95.5%-100%) were the most active antimicrobials. Ertapenem activity, unlike amoxicillin-clavulanate or piperacillin-tazobactam, remained virtually unchanged in ESBL (100%) and non-ESBL (98.8%) E. coli producers. Its activity decreased in ESBL-K. pneumoniae (74.7%) but was higher than that of amoxicillin-clavulanate (14.0%) and piperacillin-tazobactam (24.0%). Interestingly, ertapenem susceptibility was maintained in >60% of ESBL isolates that were resistant to amoxicillin-clavulanate, piperacillin-tazobactam or fluoroquinolones. Conclusions: SMART-Spain results support current guidelines which include ertapenem as empiric treatment in mild-moderate community-acquired IAI, particularly with ESBL producers. These recommendations will need to be updated with the recently introduction of new antimicrobials.

La presente investigación tuvo como objetivo determinar el grado de relación entre la Gestión de Adquisiciones y Contrataciones y la Ejecución Presupuestal en la Dirección Regional de Salud de Madre de Dios durante el año 2017. Así mismo, se tomó como hipótesis general si existe un grado de relación significativa entre la gestión de adquisiciones y contrataciones y la ejecución presupuestal de la Dirección Regional de Salud de Madre de Dios - 2017. El tipo de estudio fue básico, diseño no experimental transversal de nivel descriptivo correlacional, la población de estudio estuvo conformada por 53 trabajadores de la sede de la Dirección Regional de Salud de Madre de Dios, los datos se obtuvieron a través de la realización de una encuesta, constituida por 50 preguntas en escala de Likert. Se ha preparado un cuestionario de 25 preguntas para la variable Gestión de adquisiciones y contrataciones, y otras 25 preguntas para la variable Ejecución presupuestal, se tabularon y se procesaron los datos en el paquete estadístico SPSS. Finalmente, Se concluye que existe una relación directa y significativa entre gestión de adquisiciones y contrataciones y la ejecución presupuestal en la Dirección regional de salud de Madre de Dios durante el año 2017. Trujillo Escuela de Posgrado Gestión de Políticas Públicas.

Tesis descargada de TESEO Objetivos: Describir las características clínicas de las pacientes afectadas de trastornos de la fertilidad que han recibido tratamiento osteopático. Material y Métodos: Estudio analítico observacional, descriptivo, transversal con un grupo de estudio con intervención terapéutica, no aleatorizado y abierto, observando las características clínicas de las pacientes afectadas por trastornos de la fertilidad. Por un lado, 75 pacientes (n=75) con trastornos de la fertilidad (35,36 ± 3,3 años) recibieron tratamiento de osteopatía para favorecer el éxito en su embarazo, es decir, para conseguir un embarazo. Por otro lado, 99 mujeres (n=99), tanto afectadas por trastornos de la fertilidad como sanas, de las cuales el grupo de enfermas (o grupo de casos) (n=82; edad media 35 ± 4 años) presentaba alteraciones de la fertilidad y el grupo de sanas (o grupo de controles) (n=17; edad media 27 ± 4 años) no presentaban alteraciones de la fertilidad. Resultados: Observamos que en el grupo de enfermas la mayor prevalencia se atribuye a la disfunción pélvica en torsión sacra (n=58; 58,59%), seguida de la disfunción craneal en compresión esfenobasilar (SEB) (n=53; 53,54%), y de la lesión en la posición del útero en anterversión (n=29; 29,29%), presentando además disfunción lumbar en L5 (n=27; 27,27%)(gráfico 4). Sin embargo, en el grupo de sanas encontramos que la mayoría no presentaban ninguna disfunción craneal (n=11; 11,11%), tampoco lumbar (n=8; 8,08%), ni en la posición del útero (n=16; 16,16%) , aunque presentaron mayor prevalencia de lesión del coxis (n=9; 9,09%). Observamos que existe asociación entre el éxito en el embarazo y la presencia /ausencia de endometriosis (p=0,022), y además con el número de sesiones aplicadas, cuando se considera la dicotomización a 1 sesión (p=0,009), pero no existe asociación con el resto de variables (p>0,05). Observamos que la alteración de la fertilidad es 148 veces más probable cuando las pacientes presentan lesión del útero (OR=148,000: IC: 17,275-1267,944), la lesión de torsión sacra presenta un riesgo 7 veces superior entre los casos (enfermas) (OR=7,854; IC: 2,325-26,535) frente a los controles (sanas), la alteración craneal es 7 veces mayor entre los casos (enfermas) (OR=7,010; IC: 2,267-21,677), la alteración lumbar es 4 veces más probable entre los casos (OR=4,317; IC: 1,419-13,135) y la compresión esfenobasilar presenta una tasa de riesgo 3 veces superior entre los casos frente a los controles (OR=3,351; IC: 1,123-9,994). Conclusiones: La mayoría de las pacientes con trastornos de la fertilidad presentan alteraciones en la posición del útero, sin presencia de malformaciones uterinas, ni alteraciones de ablación de las trompas uterinas, ni endometriosis, con disfunciones en la pélvis, en la zona lumbar, a nivel craneal y tienen alteraciones posturales dorsales. Existe asociación entre el éxito en el embarazo y la presencia /ausencia de endometriosis y además con el número de sesiones aplicadas. Los casos tienen mayor prevalencia en la disfunción pélvica en torsión sacra, en la disfunción craneal en compresión esfenobasilar y en la lesión en la posición del útero en anterversión, con disfunción lumbar en L5. Los controles no presentan ninguna disfunción craneal, tampoco lumbar, ni en la posición del útero, aunque tienen mayor prevalencia de lesión del coxis. Existe una asociación significativa entre los grupos de estudio en la presencia de alteracion craneal, lumbar, lesión del coxis, lesión del útero, compresión esfenobasilar (SEB) , lesión en L3, lesión de torsión del sacro, lesión de anteversión del útero, lesión de retroversión del útero y lesión de anteversión y lateroversión del útero. Los trastornos de la fertilidad son 148 veces más probables cuando las pacientes presentan lesión del útero, 7 veces más probables asociadas a lesión de torsión sacra, 4 veces más probables con alteraciones lumbares y 3 veces más probables con compresión esfenobasilar asociada. Palabras Clave: Infertility, Female; Uterus; Uterine Retroversion; Fallopian Tubes; Menstrual Cycle; Endometrial Neoplasms; Ovary; Osteopathic Medicine; Physical Therapy Modalities.

Cantón, Rafael et al. [Introduction] The SMART (Study for Monitoring Antimicrobial Resistance Trends) surveillance study records the antimicrobial susceptibility of Gram-negative bacilli obtain from intraabdominal infections with special focus in isolates with extended spectrum β-lactamases (ESBLs). [Material and Methods] The antimicrobial susceptibility of 8,869 isolates was analyzed by microdilution during the SMART study performed in Spain from 2002 to 2010. Isolates were recovered in 16 centres. [Results] Escherichia coli was the most prevalent pathogen (60.9% from intraabdominal infections acquired in the community and 49.9% in those from nosocomial origin) followed by Klebsiella pneumoniae (8.9% vs 9.2%). Pseudomonas aeruginosa was more common in intraabdominal infections from nosocomial origin (5.6% community and 8.6% nosocomial). Frequency of ESBL-producing isolates was: E. coli, 8.7%; K. pneumoniae, 8.4%; Klebsiella oxytoca, 1.4%; and Proteus mirabilis, 1.6%. Overall, ESBL-producing isolates were more frequently isolated from elderly patients (6.8% >60 years). Ertapenem and meropenem were the most active antimicrobials (susceptibility range with EUCAST criteria, 89.0-100%) when considering all Enterobacteriaceae isolates and also against ESBL producers (95.5-100%). Susceptibility of amoxicillin/clavulanic acid and piperacillin/tazobactam was lower, particularly among ESBL-producing isolates. Nevertheless, ertapenem maintained a good activity (susceptibility >95%) in ESBL-producers that were resistant to amoxicillin/clavulanic acid, piperacillin/tazobactam or fluoroquinolones. [Conclusions] Antimicrobial susceptibility data from the SMART-Spain study reinforce current therapeutic guidelines of intraabdominal infections that include ertapenem as the empirical choice for treatment. This is also supported by the high frequency of ESBL-producers in our geographic area.

Cantón, Rafael et al., [Introduction] The SMART (Study for Monitoring Antimicrobial Resistance Trends) surveillance study records the antimicrobial susceptibility of Gram-negative bacilli obtain from intraabdominal infections with special focus in isolates with extended spectrum β-lactamases (ESBLs)., [Material and Methods] The antimicrobial susceptibility of 8,869 isolates was analyzed by microdilution during the SMART study performed in Spain from 2002 to 2010. Isolates were recovered in 16 centres., [Results] Escherichia coli was the most prevalent pathogen (60.9% from intraabdominal infections acquired in the community and 49.9% in those from nosocomial origin) followed by Klebsiella pneumoniae (8.9% vs 9.2%). Pseudomonas aeruginosa was more common in intraabdominal infections from nosocomial origin (5.6% community and 8.6% nosocomial). Frequency of ESBL-producing isolates was: E. coli, 8.7%; K. pneumoniae, 8.4%; Klebsiella oxytoca, 1.4%; and Proteus mirabilis, 1.6%. Overall, ESBL-producing isolates were more frequently isolated from elderly patients (6.8% >60 years). Ertapenem and meropenem were the most active antimicrobials (susceptibility range with EUCAST criteria, 89.0-100%) when considering all Enterobacteriaceae isolates and also against ESBL producers (95.5-100%). Susceptibility of amoxicillin/clavulanic acid and piperacillin/tazobactam was lower, particularly among ESBL-producing isolates. Nevertheless, ertapenem maintained a good activity (susceptibility >95%) in ESBL-producers that were resistant to amoxicillin/clavulanic acid, piperacillin/tazobactam or fluoroquinolones., [Conclusions] Antimicrobial susceptibility data from the SMART-Spain study reinforce current therapeutic guidelines of intraabdominal infections that include ertapenem as the empirical choice for treatment. This is also supported by the high frequency of ESBL-producers in our geographic area.