Score de candidemia

A bedside scoring system (“Candida score”) for early antifungal
treatment in nonneutropenic critically ill patients with Candida
colonization*

Objective: To obtain a score for deciding early antifungal
treatment when candidal infection is suspected in nonneutropenic
critically ill patients.
Design: Analysis of data collected from the database of the
EPCAN project, an ongoing prospective, cohort, observational,
multicenter surveillance study of fungal infection and colonization
in intensive care unit (ICU) patients.
Setting: Seventy-three medical-surgical ICUs of 70 teaching
hospitals in Spain.
Patients: A total of 1,699 ICU patients aged 18 yrs and older
admitted for at least 7 days between May 1998 and January 1999
were studied.
Interventions: Surveillance cultures of urine, tracheal, and
gastric samples were obtained weekly. Patients were grouped as
follows: neither colonized nor infected (n
719), unifocal or
multifocal Candida colonization (n
883), and proven candidal
infection (n
97). The odds ratio (OR) for each risk factor
associated with colonization vs. proven candidal infection was
estimated. A logistic regression model was performed to adjust
for possible confounders. The “Candida score” was obtained
according to the logit method. The discriminatory power was
evaluated by the area under the receiver operating characteristics
curve.
Measurements and main results: In the logit model, surgery
(OR
2.71, 95% confidence interval [CI], 1.45–5.06); multifocal
colonization (OR
3.04, 95% CI, 1.45– 6.39); total parenteral
nutrition (OR
2.48, 95% CI, 1.16 –5.31); and severe sepsis (OR

7.68, 95% CI, 4.14 –14.22) were predictors of proven candidal
infection. The “Candida score” for a cut-off value of 2.5 (sensitivity
81%, specificity 74%) was as follows: parenteral nutrition,
0.908; surgery, 0.997; multifocal colonization, 1.112; and
severe sepsis, 2.038. Central venous catheters were not a
significant risk factor for proven candidal infection (p
.292).
Conclusions: In a large cohort of nonneutropenic critically ill
patients in whom Candida colonization was prospectively assessed,
a “Candida score” >2.5 accurately selected patients who
would benefit from early antifungal treatment. (Crit Care Med
2006; 34:730–737)
KEY WORDS: Candida colonization; intensive care unit; critically
ill patients; Candida score; preemptive antifungal therapy; invasive
candidiasis Ver artículo completo
Gracias a Romina Hansen por acercarnos el artículo

El Mercante en el 6 Congreso de SADI

El siguiente trabajo fue aceptado para el VI Congreso de la Sociedad Argentina de Infectología SADI 2006. Gracias y felicitaciones a todos.

BROTE DE INFECCIONES OSEAS POR ACINETOBACTER BAUMANNII PAN –RESISTENTE (ABPR) (RESISTENTE A CARBAPENEMS)
Valiente, J; Acevedo, M; Marcos, H; Manonelles, G; Bognani, S; Sandoval, F; Ávila, P;
Paiz, A; Paladino, D; Tommasi, S.

Hospital “ Domingo Mercante”, José C. Paz, Bs. As. Argentina
Jvaliente@telered.com.ar

Introducción: Acinetobacter Baumannii, prevalente en infecciones nosocomiales puede resistir en el ambiente, y a múltiples antibióticos. La osteomielitis es un desafío dada la difícil penetración de los antimicrobianos en el hueso y a las limitadas opciones en el caso de ABPR.
Objetivos: Describir un brote de osteomielitis, causada por ABPR, OXA 23/27 positiva..
Material y Métodos: Se definió como “caso” todo paciente con infección ósea demostrada por biopsia con cultivo para AB. Se confecciono una ficha de seguimiento, se revisaron retrospectivamente los registros de bacteriología. La identificación y resistencia fueron confirmadas en el Instituto Malbran
Resultados: Entre 3/6/05 y 5/9/05, se identifica AB en muestras óseas de 6 pacientes No había osteomielitis por AB previamente. Cinco de los 6 casos ocurrieron entre el 31/8/05 y 5/9/05. El día 1/9/05 se iniciaron medidas de aislamiento y el estudio del brote. Se realizo un relevamiento ambiental sin poder identificarse una fuente común. El brote cesa el día 5/9/05. Los pacientes fueron tratados con colistin a dosis de 100mg, c/12 hs. Por 45 días en promedio y luego recibieron minociclina. Todos tuvieron buena evolución clínica hasta la fecha. Una paciente reingresa por osteomielitis pero el nuevo cultivo óseo mostró SAMR y no se aisló AB. No hubo toxicidad renal. El estudio bacteriológico confirma resistencia a todos los ATB, excepto Colistin y tetraciclinas. Las cepas fueron BLEE y MBL (-) blaOXA-GVI y blaOXA23/27 (+)
Conclusiones: Se describe un brote de AB pan resistente OXA 23/27, que afecto a 6 pacientes. Los mismos presentaron osteomielitis. No pudo determinarse el modo de trasmisión, aunque lo más probable es que halla sido de paciente a paciente. El brote cesa luego de que se tomaran medidas de aislamiento de contacto y se disminuyeran las intervenciones quirúrgicas traumatológicas. Los pacientes recibieron colistin y minociclina con buena evolución y tolerancia;

Caso clínico: tres meses de tratamiento

El mismo paciente de las fotos anteriores, tres meses después de iniciar tratamiento.

Stafilococo meticilino resistente de la comunidad. un patógeno emergente

Community-Acquired MRSA: Evolving Pathogens
William T. Basco, Jr., MD

The Pediatric Academic Societies Annual Meeting was held May 14-17, 2005 at the Washington, DC Convention Center. Over 5000 participants attended the meeting. Medscape conference coverage will include an update on methicillin-resistant Staphylococcus aureus (MRSA), particularly community-acquired MRSA (CA-MRSA), a brief update on immunizations, and an extensive review of research on the obesity epidemic in the United States and the metabolic syndrome.
Epidemiology Overview

A "Hot Topic" session sponsored jointly by the PAS and the Pediatric Infectious Diseases Society focused on the increasing difficulties posed by CA-MRSA. The epidemiology of MRSA was described by Daniel Jernigan,[1] Centers for Disease Control and Prevention, Atlanta, Georgia. He noted that when MRSA resistance began in the 1970s it was mostly a phenomenon of strains isolated within hospitals. However, by the late 1990s or certainly early 2000's, CA-MRSA had emerged.

Defining a strain as CA-MRSA is not as easy as it may seem. In the final analysis, it is more of a syndromic diagnosis. In order to consider an MRSA isolate as "community associated," the patient should not have had a recent hospitalization, recent in-dwelling catheters or other hardware, or have undergone any surgical procedure within the past year. In addition, CA-MRSA should have an antibiotic sensitivity profile that demonstrates sensitivity to most antibiotics, in contrast to the profile of healthcare associated MRSA (HA-MRSA). http://www.medscape.com/viewarticle/507869

Solución del Caso Clínico: Mycobacterium Marinum

Se realizón punción de las lesiones. El directo fue BAAR (+). Reinterrogando al paciente, refiere haber limpiado una pecera días antes de comenzar con las lesiones. El cultivo fue (+) para Mycobacterium Marinum.

Foto por gentileza de la Dra. Laura Boucai.

Antibiotic Lock Technique: Review of the Literature

Las infecciones relacionadas a catéteres son frecuentemente fuente de bacteriemia. Los pacientes con catéteres de larga duración ( implantables etc.) presentan un serio dilema ya que, sacar el catéter no es una decisión fácil. Este artçulo es una revisión muy interesante de la técnica de "lock therapy" que consiste en colocar el antibiótico en el catéter con o sin heparina, y dejarlo actuar localmente con el propósito de erradicar la colonización del mismo. Pueden ver el artículo completo en http://www.medscape.com/viewarticle/500842


Antibiotic Lock Technique: Review of the Literature

Megan B. Bestul, Pharm.D.; Heather L. VandenBussche, Pharm.D.

Pharmacotherapy. 2005; 25 (2): 211-227. ©2005 Pharmacotherapy Publications
Abstract and Introduction
Abstract

Central venous catheters (CVCs) are frequently used for patients requiring long-term venous access. Catheter-related infection is a serious complication associated with extended use of a CVC and can result in catheter removal. The antibiotic lock technique, a controversial method for sterilizing the catheter lumen, involves instilling high concentrations of antibiotics with or without heparin into the catheter lumen for extended periods of time. Studies differ regarding the choice and concentrations of antibiotics, dwell times in the catheter lumen, presence of heparin in the antibiotic lock technique solution, use of systemic antibiotics with the technique, and use of the technique for prevention or treatment of catheter-related infections. Results of in vitro studies demonstrate that many antibiotic combinations are stable and maintain high drug concentrations for prolonged periods of time. In vivo studies report the success of multiple combinations for both prevention and treatment with antibiotic lock technique in salvaging these catheters.
Introduction

href="http://www.medscape.com/viewarticle/500842">http://www.medscape.com/viewarticle/500842