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Resumen Objetivo Analizar los datos epidemiologicos de las infecciones del tracto urinario relacionadas con sonda uretral (ITU-SU) en pacientes criticos ingresados en UCI espanolas para evaluar la necesidad de aplicar un programa de intervencion a nivel nacional para disminuir dichas infecciones. Diseno Analisis retrospectivo, no intervencionista, de prevalencia de periodo anual. Ambito UCI participantes en el registro multicentrico ENVIN-UCI entre los anos 2007-2016. Pacientes Pacientes criticos ingresados en UCI con ITU-SU. Variables principales Tasa de incidencia por 1.000 dias de utilizacion de SU; ratio de uso de SU; proporcion de ITU-SU con respecto del total de infecciones relacionadas con asistencia sanitaria (IRAS) controladas en el registro. Resultados Se han incluido 187.100 pacientes de los que 137.654 (73,6%) utilizaron SU durante 1.215.673 dias (84,4% de los dias de estancia en UCI). En 4.539 (3,3%) pacientes sondados se han diagnosticado 4.977 ITU-SU (3,6 episodios por 100 pacientes con SU). La tasa de incidencia de ITU-SU ha disminuido entre los anos 2007 y 2016 un 19% (4,69 a 3,8 episodios por 1.000 dias de SU), aunque se ha mantenido la ratio de uso de SU (0,84 [0,82-0,86]). La proporcion de las ITU-SU ha aumentado desde el 23,3% al 31,9% del total de IRAS controladas. Conclusiones Aunque han disminuido las tasas de ITU-SU estas infecciones han pasado a ser, proporcionalmente, la primera de las IRAS en UCI. Persiste una elevada ratio de utilizacion de SU en UCI espanolas. Existe un espacio de mejora, por lo que un proyecto ITU-ZERO podria ser util en nuestro pais.

Objective To analyze epidemiological data of catheter-associated urinary tract infection (CAUTI) in critically ill patients admitted to Spanish ICUs in order to assess the need of implementing a nationwide intervention program to reduce these infections. Design Non-intervention retrospective annual period prevalence analysis. Setting Participating ICUs in the ENVIN-UCI multicenter registry between the years 2007 and 2016. Patients Critically ill patients admitted to the ICU with catheter-associated urinary tract infection (CAUTI). Main variables Incidence rates per 1000 catheter-days; urinary catheter utilization ratio; proportion of CAUTIs in relation to total health care-associated infections (HAIs). Results A total of 187,100 patients, 137,654 (73.6%) of whom had a urinary catheter in place during 1,215,673 days (84% of days of ICU stay) were included. In 4539 (3.3%) patients with urinary catheter, 4977 CAUTIs were diagnosed (3.6 episodes per 100 patients with urinary catheter). The CAUTI incidence rate showed a 19% decrease between 2007 and 2016 (4.69–3.8 episodes per 1000 catheter-days), although a sustained urinary catheter utilization ratio was observed (0.84 [0.82–0.86]). The proportion of CAUTI increased from 23.3% to 31.9% of all HAIs controlled in the ICU. Conclusions Although CAUTI rates have declined in recent years, these infections have become proportionally the first HAIs in the ICU. The urinary catheter utilization ratio remains high in Spanish ICUs. There is room for improvement, so that a CAUTI-ZERO project in our country could be useful.

OBJECTIVE: To analyze epidemiological data of catheter-associated urinary tract infection (CAUTI) in critically ill patients admitted to Spanish ICUs in order to assess the need of implementing a nationwide intervention program to reduce these infections. DESIGN: Non-intervention retrospective annual period prevalence analysis. SETTING: Participating ICUs in the ENVIN-UCI multicenter registry between the years 2007-2016. PATIENTS: Critically ill patients admitted to the ICU with catheter-associated urinary tract infection (CAUTI). MAIN VARIABLES: Incidence rates per 1,000 catheter-days; urinary catheter utilization ratio; proportion of CAUTIs in relation to total health care-associated infections (HAIs). RESULTS: A total of 187,100 patients, 137,654 (73.6%) of whom had a urinary catheter in place during 1,215,673 days (84% of days of ICU stay) were included. In 4,539 (3.3%) patients with urinary catheter, 4,977 CAUTIs were diagnosed (3.6 episodes per 100 patients with urinary catheter). The CAUTI incidence rate showed a 19% decrease between 2007 and 2016 (4.69 to 3.8 episodes per 1,000 catheter-days), although a sustained urinary catheter utilization ratio was observed (0.84 [0.82-0.86]). The proportion of CAUTI increased from 23.3% to 31.9% of all HAIs controlled in the ICU. CONCLUSIONS: Although CAUTI rates have declined in recent years, these infections have become proportionally the first HAIs in the ICU. The urinary catheter utilization ratio remains high in Spanish ICUs. There is room for improvement, so that a CAUTI-ZERO project in our country could be useful.

Resumen La presencia de una infeccion fungica respiratoria en un paciente critico se asocia con una elevada morbimortalidad. Objetivos Determinar la incidencia de infeccion respiratoria por Aspergillus spp. en pacientes ingresados en UCI espanolas, independientemente del origen de la misma, asi como describir las tasas, caracteristicas, evolucion y factores pronostico de los pacientes con dicha infeccion. Material y metodo Estudio retrospectivo, abierto, observacional y multicentrico que analiza la cohorte de pacientes con infeccion respiratoria por Aspergillus spp. ingresados en UCI espanolas entre los anos 2006-2012 (meses de abril, mayo y junio), incluidos en el registro nacional ENVIN-HELICS (108.244 pacientes y 825.797 dias de estancia-UCI). Las variables relacionadas de forma independiente con mortalidad hospitalaria se han identificado mediante analisis de regresion logistica multiple. Resultados Se han incluido 267 pacientes en 79 de las 198 UCI participantes (2,46 casos por 1.000 pacientes ingresados en UCI y de 3,23 episodios por 10.000 dias de estancia en UCI). Las infecciones se clasificaron desde un punto de vista clinico como neumonia relacionada con ventilacion mecanica en 93 (34,8%) casos, neumonia no relacionada con ventilacion mecanica en 120 (44,9%) y traqueobronquitis en 54 (20,2%). Se trata de pacientes de edad avanzada (64,8 ± 17,1 anos), con un elevado nivel de gravedad (APACHE II: 22,03 ± 7,7), con enfermedad medica (64,8%), estancia prolongada en el hospital previa a la identificacion del Aspergillus spp. (mediana 11 dias), procedencia de salas de hospitalizacion (58,1%) y elevada mortalidad intra-UCI (57,3%) y hospitalaria (59,6%), con importantes diferencias dependiendo del tipo de infeccion. Los factores con riesgo independiente de mortalidad han sido: ingreso previo en una unidad de hospitalizacion (OR: 7,08; IC 95%: 3,18-15,76), antecedente de inmunosupresion (OR: 2,52; IC 95%: 1,24-5,13) y presencia de sepsis grave o shock septico (OR: 8,91; IC 95%: 4,24-18,76). Conclusiones La tasa de infeccion respiratoria por Aspergillus spp. en pacientes criticos ingresados en UCI en Espana es baja, afectando a un grupo muy seleccionado de pacientes, cuya mortalidad hospitalaria es elevada y condicionada por factores no modificables.

Objective: In recent years there has been an increase in infections caused by gram-positive cocci in critical patients, together with a rapid development of resistance to the antibiotics which are normally used to treat them. The objective is to prepare an antibiotic treatment guide for the most common infections caused by gram positive cocci in critical patients. This guide will help in the decision-making process regarding the care of such patients. Method: Experts from two scientific societies worked together to prepare a consensus document. They were members of the Study Group on Infections in Critical Patients (GEIPC), which is part of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), and the Infectious Diseases Working Group (GTEI), belonging to the Spanish Society of Intensive Care Medicine and Coronary Units (SEMICYUC). There was a systematic review of the literature published up to September 2006 regarding this type of infections and the antibiotic treatments marketed to that date. An evidence grading system was applied according to the strength of the recommendation (categories A, B or C) and the level of evidence (categories I, II or III). Recommendations were given if there was consensus among the experts from both societies. Results: The antibiotic regimens recommended for treating infections caused by gram-positive cocci were presented in the form of tables, showing the recommendation grade. Alternatives were given for allergic patients. The scientific basis supporting the aforementioned recommendations is explained within the text and the references upon which they are based are cited. Conclusions: A summary of an evidence-based practical guide for the treatment of infections caused by gram-positive cocci in critical patients is presented.

Piperacilin-tazobactam (TZP) and meropenem (MER) are two extended-spectrum beta-lactams antibiotics (ATB) broadly used in intensive care units. We know that early and appropriate ATB treatment remains the most important intervention in septic patients, so optimization of ATB administration should be a priority.

Multiresistant bacteria (MRB) development is a growing phenomenon. In 2013, the “Zero Resistance” (RZ) program was launched in Spain, to help prevent the emergence of multiresistant bacteria (MRB) in critically ill patients. One of its recommendations is to complete a checklist upon patient admission in Intensive Care Unit (ICU) to identify those patients at high risk for colonization or infection by MRB*.

In 2013, the “Zero Resistance” (RZ) program was launched in Spain, to help prevent the emergence of multiresistant bacteria (MRB) in critically ill patients. One of its recommendations is to complete a checklist upon patient admission in Intensive Care Unit (ICU) to identify those patients at high risk for colonization or infection by MRB*.

Objetivo Identificar las tasas nacionales de las infecciones hospitalarias adquiridas en Unidades de Cuidados Intensivos (UCI) relacionadas con instrumentalizacion, correspondientes al ano 2002, asi como conocer sus etiologias y la evolucion de las resistencias de aquellos microorganismos mas prevalentes. Diseno Estudio de serie de casos, observacional y prospectivo. Ambito 85 UCI, servicios o unidades de Cuidados Intensivos u otras unidades en donde se ingresan pacientes criticos, pertenecientes a 80 hospitales distintos. Pacientes y metodos Se han incluido de forma continuada los pacientes ingresados durante mas de 24 horas en las UCI participantes, que fueron seguidos hasta su alta de UCI o hasta un maximo de 30 dias. Las infecciones objeto de vigilancia han sido: neumonias relacionadas con ventilacion mecanica (N-VM), infecciones urinarias relacionadas con sonda uretral (IU-SU), bacteriemias primarias (BP) y relacionadas con cateteres vasculares (B-CVC) y bacteriemias secundarias. Resultados Se han incluido 6.868 pacientes. En 684 (10%) pacientes se han detectado 1.019 infecciones, 445 N-VM (43,7%), 229 IU-SU (22,5%), 100 BP (9,8%), 135 B-CVC (13,2%) y 110 bacteriemias secundarias (10,8%). Las densidades de incidencia en relacion con los dias de exposicion al factor de riesgo han sido 18,0 N-VM por 1.000 dias de ventilacion mecanica, 6,0 IU-SU por 1.000 dias de sonda uretral y 4,5 BP-CVC por 1.000 dias de cateter venoso central. La etiologia predominante en las N-VM precoces ha sido Staphylococcus aureus sensible a meticilina y Haemophilus influenzae y en las N-VM tardias Pseudomonas aeruginosa y Acinetobacter baumannii. Las IU-SU han estado originadas predominantemente por Escherichia coli y Enterococcus faecalis y las BP-CVC por Staphylococcus epidermidis y Staphylococcus coagulasa negativo. Entre los marcadores de resistencia destacan por su frecuencia: P. aeruginosa resistente a imipenem-cilastatina (34,7%) y a ceftazidima (29,5%), S. aureus resistente a meticilina (35,3%), A. baumannii resistente a imipenem (33,9%) y E. coli resistente a ciprofloxacino (20,0%). No se ha detectado ninguna cepa de Enterococcus spp. o de Staphylococcus aureus resistente a vancomicina. Conclusiones Se han identificado, para el ano 2002, las tasas nacionales de las infecciones nosocomiales relacionadas con ventilacion mecanica, sonda uretral y cateter venoso central, asi como los agentes patogenos que predominan en cada una de ellas y el estado de los marcadores de multirresistencia.

Fundamento Analizar la incidencia de infeccion nosocomial (IN) en una UCI polivalente de nivel II, y evaluar el efecto de la utilizacion de sucralfato y la aplicacion de medidas estrictas de asepsia sobre las distintas tasas de IN. Material y metodos Se ha llevado a cabo un estudio prospectivo de cohortes, de 2 anos de duracion, sobre 400 pacientes distribuidos en dos grupos, grupo A (n = 200), observacional, y grupo B (n = 200), en el que se aplicaron medidas de mejora basadas en la administracion de sucralfato, cumplimiento de la profilaxis antibiotica posquirurgica y medidas estrictas de asepsia en las distintas instrumentalizaciones. Se han comparado las tasas de IN asociada a ventilacion mecanica (NAVM), infeccion urinaria relacionada con sonda uretral, bacteriemia vinculada a infeccion de cateter venoso central e infeccion de herida quirurgica entre ambos grupos, asi como la mortalidad intra-UCI. Resultados En el grupo A, 29 pacientes desarrollaron una o mas IN frente a 18 en el grupo B (p = 0,06). No apreciamos diferencias en la mortalidad global intra-UCI entre ambos grupos (10,5 frente a 10%; p = 0,89), aunque si en la mortalidad de los pacientes con diagnostico de IN (57,1 frente a 25%; p = 0,03). En aquellos que desarrollaron una NAVM, observamos una reduccion no significativa de la tasa de mortalidad (60 frente a 50%; grupo A y B). A pesar de la reduccion lograda en los indicadores de IN, el nivel de incumplimientos del protocolo de intervenciones de mejora propuesto para el control de la IN fue elevado. Conclusiones Nuestros resultados se situan en un nivel aceptable dentro del contexto de los estandares admitidos sobre IN en UCI. La instauracion de un sistema de vigilancia y la aplicacion de medidas de mejora han logrado reducir tanto la incidencia como la mortalidad de la IN, no asi la mortalidad global intra-UCI.

The presence of respiratory fungal infection in the critically ill patient is associated with high morbidity and mortality.To assess the incidence of respiratory infection caused by Aspergillus spp. independently of the origin of infection in patients admitted to Spanish ICUs, as well as to describe the rates, characteristics, outcomes and prognostic factors in patients with this type of infection.An observational, retrospective, open-label and multicenter study was carried out in a cohort of patients with respiratory infection caused by Aspergillus spp. admitted to Spanish ICUs between 2006 and 2012 (months of April, May and June), and included in the ENVIN-HELICS registry (108,244 patients and 825,797 days of ICU stay). Variables independently related to in-hospital mortality were identified by multiple logistic regression analysis.A total of 267 patients from 79 of the 198 participating ICUs were included (2.46 cases per 1000 ICU patients and 3.23 episodes per 10,000 days of ICU stay). From a clinical point of view, infections were classified as ventilator-associated pneumonia in 93 cases (34.8%), pneumonia unrelated to mechanical ventilation in 120 cases (44.9%), and tracheobronchitis in 54 cases (20.2%). The study population included older patients (mean 64.8±17.1 years), with a high severity level (APACHE II score 22.03±7.7), clinical diseases (64.8%) and prolonged hospital stay before the identification of Aspergillus spp. (median 11 days), transferred to the ICU mainly from hospital wards (58.1%) and with high ICU (57.3%) and hospital (59.6%) mortality rates, exhibiting important differences depending on the type of infection involved. Independent mortality risk factors were previous admission to a hospital ward (OR=7.08, 95%CI: 3.18-15.76), a history of immunosuppression (OR=2.52, 95%CI: 1.24-5.13) and severe sepsis or septic shock (OR=8.91, 95%CI: 4.24-18.76).Respiratory infections caused by Aspergillus spp. in critically ill patients admitted to the ICU in Spain are infrequent, and affect a very selected group of patients, characterized by high mortality and conditioned by non-modifiable risk factors.

to assess the applicability on a national level of the interventions proposed by Peter Pronovost et al in Michigan state for the prevention of central vascular catheter-related bacteremia (B-CVC) in patients admitted to the ICU.pilot, prospective and comparative study.eighteen ICUs (9 control and 9 intervention) from three autonomous communities in Spain during 3 months in 2007 participated in the study.the following activities were included: a) training program for health care personnel, b) introduction of specific measures related to the insertion and care of CVC (catheter insertion checklist, basic recommendations for maintenance of central catheters, dedicated cart for venous accesses, information poster with the five procedures proposed to reduce bacteremias: hands hygiene, use of maximal aseptic barriers during insertion, asepsis of the skin at the insertion point with chlorhexidine, avoidance of the femoral access, and removal of all CVC) and c) measures aiming to promote the culture of safe daily work (daily objectives, learning from mistakes, safety rounds).the rate of B-CVC expressed as mean values has shown a half reduction as compared with historical registers. Different problems in the implementation of specific measures related to catheters and safety tools were identified.the intervention project assessed in the pilot study may be viable on the national level. It is necessary to modify and adapt to the Spanish reality the interventions proposed.

Resumen Objetivo Evaluar la aplicabilidad a nivel nacional de las intervenciones propuestas en el estado de Michigan por Peter Pronovost et al para la prevencion de B-CVC en pacientes ingresados en UCI. Diseno Estudio piloto, prospectivo y comparativo. Ambito Han participado 18 UCI (nueve control y nueve intervencion) de tres comunidades autonomas de Espana a lo largo de tres meses en el ano 2007. Intervencion Incluyo las actividades siguientes: a) programa de formacion del personal sanitario; b) introduccion de medidas especificas relacionadas con la insercion y manejo de los CVC (lista de comprobacion durante la insercion de los CVC, carro exclusivo para accesos venosos, cartel informativo con los cinco procedimientos propuestos para disminuir las bacteriemias: higiene de manos, uso de barreras asepticas maximas durante la insercion, asepsia de la piel del punto de insercion con clorhexidina, evitar la via de acceso femoral y retirar todos los CVC innecesarios, y c) medidas dirigidas a promover la cultura de seguridad en el trabajo diario (objetivos diarios, aprender de los errores, rondas de seguridad). Resultados La tasa de B-CVC expresada en medias ha disminuido a la mitad en comparacion con los registros historicos. Se identificaron diferentes problemas en la implantacion de las medidas especificas relacionadas con los cateteres y en las herramientas de seguridad. Conclusiones El proyecto de intervencion evaluado en el estudio piloto puede ser viable a nivel nacional. Es necesario modificar y adaptar a la realidad espanola las herramientas propuestas.

Resumen Objetivo En los ultimos anos se han producido cambios en el entorno de la bacteriemia relacionada con el uso de cateteres vasculares (BCV) con la aparicion de cocos grampositivos multirresistentes (CGP-MR), el conocimiento de limitaciones en los antibioticos mas utilizados para su tratamiento (glucopeptidos) y la aparicion de nuevos antibioticos activos vs. dichos patogenos. En este articulo se analiza la evolucion de las tasas, etiologias y marcadores de multirresistencia de los patogenos mas comunesen las BCV (incluidas las bacteriemias primarias) en servicios de medicina intensiva espanoles (UCI). Material y metodos Estudio de incidencia, multicentrico, prospectivo, observacional y de participacion voluntaria. Han colaborado 74, 105, 112 y 121 UCI pertenecientes a 71, 97, 103 y 112 hospitales respectivamente entre los anos 2005–2008 (ambos inclusive). Se ha utilizado la informacion incluida en el registro ENVIN-HELICS. Resultados Las tasas de esta complicacion han disminuido y se situan en torno a 5 episodios por 1.000 dias de cateter venoso central (CVC). Una tercera parte de los episodios se presentan con una importante respuesta sistemica (sepsis grave o shock septico). Los CGP-MR fueron los mas frecuentes pero los bacilos gramnegativos (BGN) se identificaron en el 30% de casos y los hongos (distintas especies de Candida) en el 6%. Los Staphylococcus epidermidis y Staphylococcus coagulasa negativa (SCN) resistentes a meticilina persisten en una proporcion superior al 80%, mientras que han disminuido los S aureus resistentes a meticilina a menos del 40%. Conclusiones El tratamiento empirico en situaciones de extrema gravedad se considera la cobertura de los patogenos mas frecuentes como son los CGP-MR y los BGN y en situaciones especiales los hongos.

In recent years, changes have occurred in the setting of bacteriemia related with the use of vascular catheters (BVC) and with the appearance of multiresistant gram positive cocci (MR-GPC), knowledge of the limitations regarding the antibiotics used most for their treatment (glycopeptides) and the appearance of new antibiotics active against these pathogens. This article analyzes the evolution of the rates, etiologies and markers of multiresistance of the most common pathogens in the BVC (including the primary bacteriemias) in the Spanish Intensive Medicine Departments (ICU).A multicenter, prospective, observational study of incidence, with voluntary participation, was conducted. A total of 74, 105, 112 and 121 ICUs belonging to 71, 97, 103 and 112 hospitals, respectively, collaborated including the years 2005-2008. The information included in the ENVIN-HELICS registry was used.The rates of this complication have decreased and are now at about 5 episodes per 1,000 days of central venous catheter (CVC). One third of the episodes occur with significant systemic response (severe sepsis or septic shock). The MR-GPC were the most frequent, however Gram-negative bacilli (GNB) were identified in 30% of the cases and fungi (different species of Candida) in 6%. Staphylococcus epidermidis and coagulase-negative, methicillin-resistant staphylococci (CNS) persist in a proportion greater than 80%, while methicillin-resistance S. aureus have decreased to less than 40%.The empirical treatment in situations of extreme seriousness should consider coverage of the most frequent pathogens such as the MR-GPC and GNB and in special conditions, the fungi.

Healthcare-associated infections (HCAI) are preventable errors. In 1999 the Institute of Medicine (IOM) released its landmark report “To err is human.” IOM estimated that as many as 100,000 patients died from medical errors in the USA, with a cost of over $50 billion/year [1]. The improvement of the quality of healthcare is a major concern for intensive care professionals because patients in the intensive care unit (ICU) are thought to be particularly at risk for errors due to the complexity of the patients, interdependence of the practitioners, and dependence on team functioning. Ensuring patients’ safety during their hospital stay requires mechanisms to determine the incidence of adverse effects. Published reports estimate that 1.7 errors per patient per day occur in the ICU and 148,000 life-threatening errors would occur annually in teaching hospital ICUs in the USA [2].

Antimicrobials are pharmaceutical drugs very frequently prescribed in the intensive care unit (ICU) setting. In the last decade, there is a growing body of evidence showing that early and appropriate use of antimicrobials has a short-term favorable impact on the course of critically ill patients [1, 2, 3, 4], whereas in the long-term, antimicrobials facilitate the appearance of emerging flora and changes in resistance patterns of pathogens that form part of the hospital ecosystem [5, 6]. Over the years, a number of guidelines and strategies have been proposed to improve and optimize the use of antimicrobials in ICU patients, which have been collectively named “antibiotic policy.”

In recent years there has been an increase in infections caused by gram-positive cocci in critical patients, together with a rapid development of resistance to the antibiotics which are normally used to treat them. The objective is to prepare an antibiotic treatment guide for the most common infections caused by gram positive cocci in critical patients. This guide will help in the decision-making process regarding the care of such patients.Experts from two scientific societies worked together to prepare a consensus document. They were members of the Study Group on Infections in Critical Patients (GEIPC), which is part of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), and the Infectious Diseases Working Group (GTEI), belonging to the Spanish Society of Intensive Care Medicine and Coronary Units (SEMICYUC). There was a systematic review of the literature published up to September 2006 regarding this type of infections and the antibiotic treatments marketed to that date. An evidence grading system was applied according to the strength of the recommendation (categories A, B or C) and the level of evidence (categories I, II or III). Recommendations were given if there was consensus among the experts from both societies.The antibiotic regimens recommended for treating infections caused by gram-positive cocci were presented in the form of tables, showing the recommendation grade. Alternatives were given for allergic patients. The scientific basis supporting the aforementioned recommendations is explained within the text and the references upon which they are based are cited.A summary of an evidence-based practical guide for the treatment of infections caused by gram-positive cocci in critical patients is presented.

En los últimos años se ha constatado un incremento en las infecciones causadas por cocos grampositivos tanto en infecciones comunitarias como nosocomiales. En algunos países, se ha observado un rápido desarrollo de resistencias a los antibióticos habitualmente empleados para su tratamiento, y se supone que esa situación puede llegar en el futuro a nuestro país. Se están desarrollando nuevos antimicrobianos específicamente dirigidos para el tratamiento de estas infecciones, pero es necesario profundizar en el conocimiento de las propiedades farmacocinéticas de los antibióticos tanto antiguos como nuevos, para aprovechar al máximo sus cualidades frente a estos patógenos y evitar en lo posible su toxicidad. En el paciente crítico estos problemas son más acuciantes, ya que la inadecuación del tratamiento, tanto en la elección del antibiótico como en la dosis y en la administración, se acompañan frecuentemente de fracasos terapéuticos y por tanto de mal pronóstico. Expertos de dos grupos de trabajo de dos Sociedades científicas, pertenecientes al Grupo de estudio de Infecciones en el Paciente Crítico de la SEIMC (GEIPC-SEIMC) y al Grupo de trabajo de Enfermedades Infecciosas de la SEMICYUC (GTEI- SEMICYUC) se han reunido con el objetivo de elaborar un documento de consenso, basado en la evidencia científica, que recoge las recomendaciones para el tratamiento antibiótico de las infecciones graves causadas por cocos grampositivos en el paciente crítico y que ayude en la toma de decisiones asistenciales. In recent years, an increment of infections caused by gram-positive cocci has been documented in nosocomial and hospital-acquired infections. In diverse countries, a rapid development of resistance to common antibiotics against gram-positive cocci has been observed. This situation is exceptional in Spain but our country might be affected in the near future. New antimicrobials active against these multi-drug resistant pathogens are nowadays available. It is essential to improve our current knowledge about pharmacokinetic properties of traditional and new antimicrobials to maximize its effectiveness and to minimize toxicity. These issues are even more important in critically ill patients because inadequate empirical therapy is associated with therapeutic failure and a poor outcome. Experts representing two scientific societies (Grupo de estudio de Infecciones en el Paciente Critico de la SEIMC and Grupo de trabajo de Enfermedades Infecciosas de la SEMICYUC) have elaborated a consensus document based on the current scientific evidence to summarize recommendations for the treatment of serious infections caused by gram-positive cocci in critically ill patients.

In recent years, an increment of infections caused by gram-positive cocci has been documented in nosocomial and hospital-acquired-infections. In diverse countries, a rapid development of resistance to common antibiotics against gram-positive cocci has been observed. This situation is exceptional in Spain but our country might be affected in the near future. New antimicrobials active against these multi-drug resistant pathogens are nowadays available. It is essential to improve our current knowledge about pharmacokinetic properties of traditional and new antimicrobials to maximize its effectiveness and to minimize toxicity. These issues are even more important in critically ill patients because inadequate empirical therapy is associated with therapeutic failure and a poor outcome. Experts representing two scientific societies (Grupo de estudio de Infecciones en el Paciente Crítico de la SEIMC and Grupo de trabajo de Enfermedades Infecciosas de la SEMICYUC) have elaborated a consensus document based on the current scientific evidence to summarize recommendations for the treatment of serious infections caused by gram-positive cocci in critically ill patients.

In recent years, an increment of infections caused by gram-positive cocci has been documented in nosocomial and hospital-acquired infections. In diverse countries, a rapid development of resistance to common antibiotics against gram-positive cocci has been observed. This situation is exceptional in Spain but our country might be affected in the near future. New antimicrobials active against these multi-drug resistant pathogens are nowadays available. It is essential to improve our current knowledge about pharmacokinetic properties of traditional and new antimicrobials to maximize its effectiveness and to minimize toxicity. These issues are even more important in critically ill patients because inadequate empirical therapy is associated with therapeutic failure and a poor outcome. Experts representing two scientific societies (Grupo de estudio de Infecciones en el Paciente Critico de la SEIMC and Grupo de trabajo de Enfermedades Infecciosas de la SEMICYUC) have elaborated a consensus document based on the current scientific evidence to summarize recommendations for the treatment of serious infections caused by gram-positive cocci in critically ill patients.

Paraquat is the most important member of the bipyridyl compound. It is directly caustic in nature and it exerts its herbicidal activity by inhibiting the reduction of NADP to NADPH during photosynthesis, a process in which superoxide, singlet oxygen, hydroxyl, and peroxide radicals are formed. Human tissue toxicity likely results from a similar oxidative mechanism. After oxidative destruction, recruitment of inflammatory cells leads to late onset and irreversible pulmonary fibrosis. Ingestion greater than 20-40 mg/kg of paraquat concentrate should be aggressively managed with the administration of intestinal decontaminants and hemoperfusion. Low-inspired oxygen therapy should be given until it becomes impractical in the face of hypoxemia. Administration of immunodepressive therapy, steroids and cyclophosphamide, should be considered. In addition, there should be intermittent assessment of pulmonary function and of plasma and urinary concentrations of paraquat.

El paraquat es el agente más importante de la familia de los biperidilos. Es directamente cáustico en la naturaleza, su actividad es herbicida mediante la reducción del NADP a NADPH durante la fotosíntesis, un proceso de superoxidación que genera radicales oxi, hidroxil y radicales peróxidos. La toxicidad en tejidos humanos resulta de forma parecida por la alteración del proceso oxidativo. Tras la destrucción oxidativa, el reclutamiento de las células inflamatorias conducen a un proceso tardío de fibrosis pulmonar. La ingesta mayor de 20-40 mg/kg de concentrado de paraquat requiere de un tratamiento agresivo con descontaminación intestinal y hemoperfusión. Igualmente, la limitación del aporte de oxígeno a bajo flujo según la hipoxemia tolerable. La administración de terapia inmunosupresora con esteroides y ciclofosfamida debe ser considerada. Igualmente debe ser controlada de forma intermitente la función pulmonar y los niveles de paraquat en plasma y orina. Paraquat is the most important member of the bipyridyl compound. It is directly caustic in nature and it exerts its herbicidal activity by inhibiting the reduction of NADP to NADPH during photosynthesis, a process in which superoxide, singlet oxygen, hydroxyl, and peroxide radicals are formed. Human tissue toxicity likely results from a similar oxidative mechanism. After oxidative destruction, recruitment of inflammatory cells leads to late onset and irreversible pulmonary fibrosis. Ingestion greater than 20-40 mg/kg of paraquat concentrate should be aggressively managed with the administration of intestinal decontaminants and hemoperfusion. Low-inspired oxygen therapy should be given until it becomes impractical in the face of hypoxemia. Administration of immunodepressive therapy, steroids and cyclophosphamide, should be considered. In addition, there should be intermittent assessment of pulmonary function and of plasma and urinary concentrations of paraquat.

The present study reviews acute intoxication by methanol and ethylenglycol analyzing its form of presentation, treatment applied and prognosis.A retrospective study performed in 5 hospitals from the Barcelona area (Spain) from January 1984 to December 1993 is reported.Eighteen patients, 16 intoxicated by methanol and 2 by ethylenglycol were reviewed. The blood levels of methanol on admission ranged from 350 to 4,600 mg/l (mean = 1,649 +/- 1,220 mg/l). The clinical course was initially characterized by alteration of the level of consciousness (in 61% the index of Glasgow of coma wasor = 7) and development of metabolic acidosis (pHor = 6.80 in 44% of cases). Eighty-seven percent of patients intoxicated by methanol had visual disorders. Treatment consisted in the administration of ethanol, bicarbonate and extrarenal exchange. Mortality was 44%, being greater among patients with the lowest initial pH (p = 0.0001) and with the lowest concentration of bicarbonates (p0.03). The patients with lower pH (r2 = 0.65, p0.002) and with a lower value of blood bicarbonate (r2 = 0.87; p0.0001) on admission were significantly more severe. Sequelae are present in 55% of the survivors.Intoxication by methanol and ethylenglycol cause severe metabolic acidosis, with high anion and osmolar gaps which may rapidly lead to death or to sequelae in survivors if diagnosis is delayed and specific treatment is not initiated early.