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Background: The 2016 cumulative incidence of Clostridioides difficile infection (CDI) in Spain was reported by the European Center for Disease Control to be above the mean of other European countries. The aim of this multicenter prospective observational cohort study was to examine the risk factors that determine 90-day CDI recurrence in Catalonia, Spain. Methods: The study included 558 consecutive adults admitted to hospital who had a symptomatic, first positive CDI diagnosis. Sociodemographic, clinical and epidemiological variables were recorded. The primary outcome was 90-day CDI recurrence. Results: In this Catalan population, having received more than one course of antibiotics in the 30 days prior to CDI diagnosis (odds ratio: 2.459; 95% CI: 1.195–5.060; p = 0.015) and active chemotherapy (odds ratio: 4.859; 95% CI: 1.495–15.792; p = 0.009) are significant predictors of 90-day CDI recurrence. Conclusion: The identification of independent risk factors of 90-day CDI recurrence will enable the optimization of preventive measures in at-risk populations.

Altres ajuts: Generalitat de Catalunya's Department de salut (SLD015); Consorcio Centro de Investigación Biomédica en Red (CB-2021) Background. Prophylactic vaccination has proven to be the most effective strategy to fight the COVID-19 pandemic. Methods. This was a prospective observational cohort study involving 30 predominantly antibody deficiency disorders (ADD)-afflicted adult patients on immunoglobulin replacement therapy vaccinated with three doses of the mRNA-1273 COVID-19 vaccine, and 10 healthy controls. Anti-RBD IgG antibodies were determined in plasma samples collected just before the first dose of mRNA-based COVID-19 vaccine and on weeks 4, 8, 24, and 28 following the first vaccination. Patients were categorized based on the levels of anti-RBD antibodies determined on w8 as non-, low-, and responders. Chi-square and Kruskal-Wallis tests were used to see if any variables correlated with humoral response levels. Any adverse effects of the mRNA-based vaccine were also noted. Results. The COVID-19 vaccine was safe and well-tolerated. The humoral response elicited at w8 after vaccination depended on the type of ADD, the type of immunoglobulin deficiency, the presence of granulomatous lymphocytic interstitial lung disease, recent use of immunosuppressive drugs, and the switched memory B cells counts. The third vaccine dose boosted humoral response in previous responders to second dose but seldom in non-responders. Conclusions: The humoral response of patients with predominant ADD depends mostly on the type of immunodeficiency and on the frequency of B and T cell populations.

Resumen Antecedentes y objetivo Las deficiencias predominantemente de anticuerpos constituyen, en la actualidad, el grupo de inmunodeficiencias primarias (IDP) mas prevalente en adultos. Son enfermedades complejas desde el punto de vista clinico, catalogadas como minoritarias y que tienen a menudo un retraso inaceptable en su diagnostico. El objetivo de este estudio fue evaluar si un mejor conocimiento de estas entidades podia conllevar un incremento en el numero de diagnosticos, una reduccion en el intervalo al diagnostico y, por ende, una disminucion en la carga de enfermedad al diagnostico. Pacientes y metodos Se diseno un estudio de intervencion casi experimental y Unicentro, que incluyo dos periodos, periodo 1 preintervencion (1986-2008) y periodo 2 postintervencion (2009-2018). Se efectuo un estudio descriptivo comparativo de diversas variables en ambos periodos. Resultados Se incluyeron 116 pacientes [27 (23,3%) en el periodo 1 y 89 (76,7%) en el periodo 2]. La tasa de incidencia aumento de forma significativa (0,204 y 1,236/100.000 habs./ano; P Conclusiones Dadas las complicaciones potencialmente graves de los pacientes con diagnostico tardio de IDP, es necesaria la creacion de unidades multidisciplinarias especializadas, la unificacion de protocolos asistenciales y el diseno de intervenciones para la divulgacion de esta entidad.

Our aim was to determine changes in the incidence of CD infection (CDI) following the introduction of a two-step diagnostic algorithm and to analyze CDI cases diagnosed in the study period. We retrospectively studied CDI (January 2009 to July 2018) in adults diagnosed by toxin enzyme immunoassay (EIA) (2009-2012) or toxin-EIA + polymerase chain reaction (PCR) algorithm (2013 onwards). A total of 443 patients with a first episode of CDI were included, 297 (67.1%) toxin-EIA-positive and 146 (32.9%) toxin-EIA-negative/PCR-positive were only identified through the two-step algorithm including the PCR test. The incidence of CDI increased from 0.9 to 4.7/10,000 patient-days (

Resumen Introduccion y objetivos En endocarditis infecciosa (EI), la decision quirurgica es dificil. Un alto porcentaje de pacientes con indicacion quirurgica no son intervenidos. El objetivo fue evaluar el pronostico a corto y largo plazo de los pacientes con indicacion quirurgica, comparando los que se sometieron a cirugia con los que no lo hicieron. Metodos Se incluyeron 271 pacientes con EI izquierda e indicacion quirurgica tratados en el centro desde 2003 a 2018. Ochenta y tres pacientes (31%) no fueron finalmente operados. El objetivo primario fue la mortalidad a 60 dias y el secundario desde el dia 61 a los 3 anos de seguimiento. Se realizo regresion de Cox multivariable y emparejamiento por puntuacion de propension. Resultados A los 60 dias, 40 (21,3%) pacientes operados y 53 (63,9%) pacientes no intervenidos fallecieron (p Conclusiones Dos tercios de los pacientes con indicacion quirurgica no intervenidos fallecieron antes de 60 dias. Entre los supervivientes, la mortalidad a largo plazo depende mas de factores relacionados con comorbilidad previa que del tratamiento recibido durante el ingreso.

INTRODUCTION AND OBJECTIVES In infective endocarditis (IE), decisions on surgical interventions are challenging and a high percentage of patients with surgical indication do not undergo these procedures. This study aimed to evaluate the short- and long-term prognosis of patients with surgical indication, comparing those who underwent surgery with those who did not. METHODS We included 271 patients with left-sided IE treated at our institution from 2003 to 2018 and with an indication for surgery. There were 83 (31%) surgery-indicated not undergoing surgery patients with left-sided infective endocarditis (SINUS-LSIE). The primary outcome was all-cause death by day 60 and the secondary outcome was all-cause death from day 61 to 3 years of follow-up. Multivariable Cox regression and propensity score matching were used for the analysis. RESULTS At the 60-day follow-up, 40 (21.3%) surgically-treated patients and 53 (63.9%) SINUS-LSIE patients died (P

Resumen Clostridioides difficile es el principal responsable de la diarrea asociada con la atencion sanitaria en adultos. La incidencia de la infeccion por C. difficile (ICD) ha aumentado en los ultimos anos. El riesgo de recidivas de la ICD es del 15-25% en un primer episodio, y este riesgo se incrementa en los posteriores episodios. Las tecnicas de referencia para el diagnostico microbiologico de la ICD son el cultivo toxigenico y el ensayo de citotoxicidad. Son tecnicas laboriosas y lentas, por lo que han sido sustituidas en la practica clinica por la aplicacion de un algoritmo de varios pasos que incluye la deteccion de glutamato deshidrogenasa (GDH), toxinas y tecnicas moleculares. El tratamiento de eleccion de la ICD es la vancomicina. En los ultimos anos han aparecido nuevos farmacos y nuevas estrategias especialmente utiles en el tratamiento de las recidivas de la ICD.

Early detection of pathogen cross-transmission events and environmental reservoirs is needed to control derived nosocomial outbreaks. Whole-genome sequencing (WGS) is considered the gold standard for outbreak confirmation, but, in most cases, it is time-consuming and has elevated costs. Consequently, the timely incorporation of WGS results to conventional epidemiology (CE) investigations for rapid outbreak detection is scarce. Fourier transform infrared spectroscopy (FTIR) is a rapid technique that establishes similarity among bacteria based on the comparison of infrared light absorption patterns of bacterial polysaccharides and has been used as a typing tool in recent studies. The aim of the present study was to evaluate the performance of the FTIR as a first-line typing tool for the identification of extended-spectrum β-lactamase-producing

Background Cancer has been associated with an increased risk of in-hospital mortality in CDI patients. However, data on delayed mortality in cancer patients with CDI are scarce. Aim/Objective The aim of the present study was to compare outcomes between oncological patients and the general population with Clostridioides difficile infection (CDI) after 90 days of follow-up. Methods A multicenter prospective cohort study was conducted in 28 hospitals participating in the VINCat program. Cases were all consecutive adult patients who met the case definition of CDI. Sociodemographic, clinical, and epidemiological variables and evolution at discharge and after 90 days were recorded for each case. Findings/results The mortality rate was higher in oncological patients (OR = 1.70, 95% CI: 1.08–2.67). In addition, oncological patients receiving chemotherapy (CT) presented higher recurrence rates (18.5% vs 9.8%, p = 0.049). Among oncological patients treated with metronidazole, those with active CT showed a higher rate of recurrence (35.3% vs 8.0% p = 0.04). Discussion Oncological patients presented a higher risk of poor outcomes after CDI. Their early and late mortality rates were higher than in the general population, and in parallel, those undergoing chemotherapy (especially those receiving metronidazole) had higher rates of recurrence

Hand hygiene (HH) is the simplest and most effective measure for the prevention of infection related to healthcare. Despite this, compliance in healthcare professionals continues to be suboptimal. The aim of this study is to assess the impact of an expanded World Health Organization (WHO) multimodal strategy on HH compliance in healthcare personnel.A quasi-experimental before-after study was designed, carrying out the expanded WHO multimodal strategy in 2018, aimed at professionals in a tertiary hospital. In this strategy, apart from applying the 5 pillars of the WHO, a video was made, the administration of the WHO perceptions questionnaire and an incentive to the service/unit with better compliance, adding to the training a modality of practical workshops. The compliance percentages for 2017 and 2018 were compared.In 2017, 1056 opportunities were observed, registering 631 HH actions, with global compliance of 60% (95% CI 56.7-62.7). In 2018, with 1481 opportunities observed and 1111 HH actions, compliance was 75% (95% CI 72.7-77.2) (P.001). This compliance increased in all professional categories and in all indications.The application of an expanded multimodal strategy has a positive impact on HH compliance. Strategies should be directed to the categories with the worst compliance and continuously over time.

Our aim was to determine changes in the incidence of CD infection (CDI) following the introduction of a two-step diagnostic algorithm and to analyze CDI cases diagnosed in the study period. We retrospectively studied CDI (January 2009 to July 2018) in adults diagnosed by toxin enzyme immunoassay (EIA) (2009–2012) or toxin-EIA + polymerase chain reaction (PCR) algorithm (2013 onwards). A total of 443 patients with a first episode of CDI were included, 297 (67.1%) toxin-EIA-positive and 146 (32.9%) toxin-EIA-negative/PCR-positive were only identified through the two-step algorithm including the PCR test. The incidence of CDI increased from 0.9 to 4.7/10,000 patient-days (p < 0.01) and 146 (32.9%) toxin-negative CDI were diagnosed. Testing rate increased from 24.4 to 59.5/10,000 patient-days (p < 0.01) and the percentage of positive stools rose from 3.9% to 12.5% (p < 0.01). CD toxin-positive patients had a higher frequency of severe presentation and a lower rate of immunosuppressive drugs and inflammatory bowel disease. Mortality (16.3%) was significantly higher in patients with hematological neoplasm, intensive care unit admission and complicated disease. Recurrences (14.9%) were significantly higher with proton pump inhibitor exposure. The two-step diagnostic algorithm facilitates earlier diagnosis, potentially impacting patient outcomes and nosocomial spread. CD-toxin-positive patients had a more severe clinical presentation, probably due to increased CD bacterial load with higher toxin concentration. This early and easy marker should alert clinicians of potentially more severe outcomes.

Background: Hospital-acquired Clostridioides difficile infection (HA-CDI) is a major infection control challenge. Using whole-genome sequencing, 500 beds), 9 hospitals; group 2 (500–200 beds), 15 hospitals; and group 3 (P < .001) and a lack of association with HA-MRSA (IRR, 0.83; 95% CI, 0.46–1.48; P = .52). Conclusions: The HA-CDI incidence rate grew annually by 5% for an increase of 1 DDD in annual antibiotic consumption. No association HA-MRSA rates was detected, suggesting that antimicrobial stewardship programs are urgently needed to improve the control of HA-CDI in Catalonia, a geographical area with a low prevalence of epidemic ribotypes.Funding: NoneDisclosures: Juan Pablo Horcajada reports consulting fees from MSD, Pfizer, and Menarini and speaker honoraria from MSD, Pfizer, and Zambon.

Clostridioides difficile is the main cause of healthcare-associated diarrhoea in adults. The incidence of C.difficile infection (CDI) has increased in recent years. The risk of recurrence of CDI is 15%-25% in a first episode and this risk is increased in subsequent episodes. Toxigenic culture and cytotoxicity tests are the reference techniques for the microbiological diagnosis of CDI. These are laborious and slow techniques and therefore they have been replaced in clinical practice by the application of a multi-step algorithm that includes the detection of glutamate dehydrogenase (GDH), toxins and molecular techniques. The treatment of choice for CDI is Vancomycin. In recent years, new drugs and new treatment strategies have appeared that are especially useful in the treatment of relapses of CDI.

Predominantly antibody deficiencies are the most prevalent primary immunodeficiency (PID) in adults. These are rare diseases difficult to diagnose. Therefore, they are diagnosed late. This study aims to evaluate whether an awareness campaign of PIDs among physicians is associated with an increase in number of diagnoses, a reduction in diagnostic delay and diagnosis at earlier stages.A single centre, interventional, quasi-experimental study was designed that included 2 periods, period 1 pre-intervention (1986-2008) and period 2 post-intervention (2009-2018). A descriptive comparative study of variables was carried out in both periods.116 patients were included [27 (23.3%) in period 1 and 89 (76.7%) in period 2]. The incidence rate increased significantly (0.204 and 1.236/100,000habs./year; P 0.05), the diagnosis delay tended to be lower (4 vs. 3.73 years). The reasons for diagnostic suspicion were diverse and the burden disease at diagnosis (expressed by bronchiectasis, altered spirometry, ability to generate antibodies by thymus-independent mechanism and need for substitute treatment) tended to decrease in period 2.Given the potentially serious complications of patients with late diagnosis of PIDs, it is necessary to create specialized multidisciplinary units, to unify assistance protocols and to design interventions to increase the knowledge of these entities.

Background: This study examines the incidence, characteristics, and risk factors of surgical site infections (SSIs) after spine surgery and evaluates the efficacy of a preventive intervention. Methods: This was a quasi-experimental pretest/posttest study in patients undergoing spinal surgery in an orthopedic surgery department from December 2014 to November 2016. Based on the results of the study, we revised the preventive protocol with modification of wound dressing, staff training, and feedback. SSI rates were compared between the pre-intervention (December 2014 to November 2015) and post-intervention (December 2015 to November 2016) periods. The risk factors were analyzed using univariate and multivariate analyses. Results: Of the 139 patients included, 14 cases of SSI were diagnosed, with a significant decrease in the incidence of SSIs from the pre-intervention period to the post-intervention period (19.4% vs 2.6%; P = .001). The etiology was known in 13 cases, with enteric flora being predominant in the pre-intervention group. Univariate analysis showed that age, body mass index, days until sitting and ambulation, and incontinence were statistically significant risk factors. After multivariate analysis, only body mass index and days until ambulation remained significant. When the effect of intervention was adjusted with other risk factors, this variable remained statistically significant. Conclusions: An intervention that includes modification of wound dressing and early mobilization, as well as staff awareness training, monitoring, and feedback, allowed a significant reduction in the incidence of SSI following spinal surgery, particularly infections caused by enteric flora. (C) 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Background: Daptomycin is an optimal choice for outpatient parenteral antibiotic therapy (OPAT) because of its safety, once-daily administration and its activity against Gram-positive bacteria. Although daptomycin is increasingly being used in OPAT, limited information about its safety in this scenario is available. Methods: We performed a prospective multicentre pilot study to evaluate the safety of daptomycin in outpatients with proved or suspected Gram-positive infections (DAPTODOM). The primary objective was to evaluate the safety and the secondary objective to evaluate the efficacy in OPAT. We also looked at the development of daptomycin resistance in those cases with microbiological failure. Results: We included 54 patients from 12 Spanish hospitals, 67% male with a mean age of 67.1 years. Most patients (87%) had chronic underlying diseases. The main reason for inclusion was skin and soft-tissue infections in 52%, followed by bacteremia or endocarditis in 34%. Staphylococcus aureus accounted for 44% of the isolates (24% were methicillin-resistant), coagulase-negative staphylococci 15% and enterococci 7%. Two patients (4%) had to be readmitted because of complications; only one patient had an adverse effect related to daptomycin (increase in serum creatine kinase levels), which disappeared after discontinuation (2%). At the end of follow-up, 96% of patients had good outcome and only 4% of patients did not have a clinical or microbiological cure. The use of a 2-minute bolus in 18 cases was not associated with adverse effects. Conclusions: Daptomycin was safe and efficacious in outpatients with Gram-positive bacterial infections and can be administered in 2-minute bolus infusion.

Resumen Introduccion VINCat es un programa de vigilancia de la infeccion nosocomial en los hospitales de Cataluna. El objetivo del estudio fue evaluar el cumplimiento de las medidas de control de Staphylococcus aureus resistente a meticilina (SARM) en dichos centros. Metodos De enero a marzo de 2013 se realizo una encuesta por correo sobre las caracteristicas de los hospitales y la aplicacion de las medidas de control de SARM. Resultados Respondieron 53 hospitales (> 500 camas: 7; 200-500 camas: 14; Conclusiones Este estudio informa sobre la implementacion de medidas preventivas de SARM en hospitales del programa VINCat. Aunque la mayoria de los hospitales disponen de un protocolo especifico, el cumplimento de las medidas es mejorable, especialmente la deteccion activa en pacientes de riesgo, la adherencia a la higiene de manos, la limpieza mas frecuente de la habitacion y la optimizacion del uso de antibioticos.

Aim: To compare the discriminatory power of pulsed-field gel electrophoresis (PFGE) and sequence-based typing (SBT) in Legionella outbreaks for determining the infection source. Materials & methods: Twenty-five investigations of Legionnaires’ disease were analyzed by PFGE, SBT and Dresden monoclonal antibody. Results: The results suggested that monoclonal antibody could reduce the number of Legionella isolates to be characterized by molecular methods. The epidemiological concordance PFGE–SBT was 100%, while the molecular concordance was 64%. Adjusted Wallace index (AW) showed that PFGE has better discriminatory power than SBT (AWSBT→PFGE = 0.767; AWPFGE→SBT = 1). The discrepancies appeared mostly in sequence type (ST) 1, a worldwide distributed ST for which PFGE discriminated different profiles. Conclusion: SBT discriminatory power was not sufficient verifying the infection source, especially in worldwide distributed STs, which were classified into different PFGE patterns.

An outbreak of Legionnaires’ disease with 113 confirmed cases was reported in the town of Mataro, Spain, in August 2002. In this study, we compared three different typing methods and characterized the clinical isolates by comparing them with other clinical isolates with the same ST from our own database to further characterize the outbreak. In the outbreak, a total of 16 clinical (nine patients) and 32 environmental (from four environmental sources) Legionella pneumophila isolates were analyzed by pulsed-field electrophoresis (PFGE), sequence-based typing (SBT), and monoclonal antibody typing (MAb). We compared the MAb and SBT profiles of the outbreak clinical isolates and other unrelated clinical isolates showing the same ST profile. We obtained seven different PFGE and SBT profiles and six MAb patterns from the outbreak isolates. PFGE and SBT showed 100 % concordance during the outbreak. SBT proved to be highly discriminatory, particularly with the addition of the new neuA gene. One PFGE, SBT (ST-37), and Philadelphia profile was observed among the clinical isolates. Using PFGE, this ST37 Philadelphia profile was closely related to other unrelated clinical isolates. These findings suggest that the ST37 Philadelphia profile could be a virulence marker in our area. The combination of the three methodologies was useful to further characterize and obtain additional information on a very explosive outbreak. Despite the minor discrimination of PFGE versus SBT, the two genetic methods are recommended in outbreak investigations. Further studies are currently underway in this area to obtain more definitive conclusions.

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of healthcare-related infection. Surveillance and prevention of MRSA is a priority in infection control programs. The aim of this study was to describe rates and trends of MRSA colonization or infection in 40 hospitals participating in the VINCat Program from 2008 to 2010. The study included all patients treated in acute care areas of participating hospitals. Hospitals were stratified into 3 groups based on size. The following annual indicators were reported: Methicillin-resistance rate, incidence density of new cases of MRSA and incidence density of MRSA bacteremia. Between 2008 and 2010, the yearly mean rate of resistance to methicillin remained stable for the study period (24%–25%), while the mean incidence of new cases of MRSA decreased from 0.65 to 0.54 cases per 1000 patient-days (p=NS) and the mean incidence of MRSA bacteremia decreased from 0.06 to 0.05 cases per 1,000 patient-days (p=NS). The implementation of a MRSA surveillance system in hospitals that participated in the VINCat Program provides information on the situation of each institution and facilitated interhospital comparisons in order to establish appropriate preventive measures.

Nosocomial pneumonia is the second most frequent cause of nosocomial infection. Most studies have been carried out in intensive care units with patients requiring mechanical ventilation or at high risk for developing nosocomial pneumonia. However, about half of the cases of nosocomial pneumonia occu

OBJECTIVES: To compare the risk factors, clinical and laboratory features, and outcome of community-acquired pneumonia (CAP) caused by Legionella pneumophila in elderly (aged ≥65) and younger patients. DESIGN: Prospective enrollment of subjects with retrospective data analysis. SETTING: A 630-bed tertiary center in Badalona (Barcelona), Spain. PARTICIPANTS: A total of 158 patients diagnosed with CAP caused by L. pneumophila from 1994 to 2004: 104 younger than 65 and 54 aged 65 and older. MEASUREMENTS: Epidemiological, clinical, laboratory, and radiological data and the outcome of the two groups were compared using univariate and multivariate analysis. RESULTS: Underlying diseases, such as chronic pulmonary diseases, diabetes mellitus, neuromuscular diseases, and heart failure; risk of aspiration; and therapy with corticosteroids were significantly more frequent in patients aged 65 and older. Patients younger than 65 were more likely to be male and have toxic habits (cigarette smoking, alcoholism) and human immunodeficiency virus infection than older patients. Fever, nonrespiratory symptoms (diarrhea and headache), and some laboratory abnormalities (hyponatremia (serum sodium concentration

VINCat is a nosocomial infection surveillance program in hospitals in Catalonia. The aim of the study was to determine the surveillance and control measures of methicillin-resistant Staphylococcus aureus (MRSA) in these centres.An e-mail survey was carried out from January to March 2013 with questions related to the characteristics of the hospitals and their control measures for MRSA.A response was received from 53 hospitals (500 beds: 7; 200-500 beds: 14;200 beds: 32; had ICU: 29). Computer alert of readmissions was available in 63%. There was active surveillance of patients admitted from another hospital (46.2%) or a long-term-care centre (55.8%), both being significantly more common measures in hospitals with a rate of MRSA≤22% (global median). Compliance with hand hygiene was observed in 77.4% of the centres, and was greater than 50% in 69.7% of them. All hospitals had contact precautions, although 62.3% did not have exclusive frequently used clinical material in bedrooms. The room cleaning was performed more frequently in 54.7% of hospitals, and 67.9% of them had programs for the appropriate use of antibiotics.This study provides information on the implementation of measures to prevent MRSA in hospitals participating in the VINCat program. Most of the centres have an MRSA protocol, however compliance with it should be improved, especially in areas such as active detection on admission in patients at risk, hand hygiene adherence, cleaning frequency and optimising the use of antibiotics.

The present study compares the risk factors, presentation and outcome of community-acquired Legionella pneumophila pneumonia in 138 sporadic-case patients (1994-2004) and 113 outbreak-case patients (2002) treated in two hospitals in Catalonia (Spain) since urinary antigen assays were adopted. Univariate and multivariate analysis were performed to compare epidemiological and clinical features, blood chemistry values, radiological findings and outcome of sporadic and epidemic legionnaires' disease. Univariate analysis showed that male sex, chronic lung disease, HIV infection and immunosuppressive therapy prevailed in sporadic cases. Presentation with respiratory symptoms, confusion and blood chemistry alterations, such as hyponatraemia, aspartate aminotransferase and blood urea nitrogen elevation, and partial pressure of oxygen P(O)(2)

La neumonia nosocomial es una de las primeras causas de infeccion nosocomial. Aunque su incidencia es mas elevada en los enfermos intubados, alrededor de la mitad de los casos se produce en las areas de hospitalizacion convencional. Sin embargo, existen pocos estudios en este ambito, por lo que la mayoria de los datos procede de series hospitalarias que incluyen a enfermos sometidos a ventilacion mecanica. Las diferencias epidemiologicas entre los enfermos intubados y los ingresados fuera de las unidades de cuidados intensivos sugieren que la etiologia y la actitud terapeutica no son totalmente equiparables en ambos grupos. En el siguiente articulo se revisa la epidemiologia, el diagnostico, el tratamiento y la prevencion de la neumonia nosocomial en las areas de hospitalizacion general.

Background Erythromycin has been the treatment of choice for Legionnaires disease (LD). However, treatment failure and experimental evidence of its bacteriostatic effect have led to evaluation of new drugs such as fluoroquinolones. This study compared the evolution of patients with LD treated with macrolides and fluoroquinolones. Methods A prospective observational study was performed, and 130 patients from three centers were included. Diagnoses were made using Legionella urinary antigen assay in all patients. Patients receiving any antibiotic > 36 h before starting the study therapy were excluded. Group 1 included 76 patients who received macrolides (33 patients with erythromycin and 43 patients with clarithromycin), and group 2 included 54 patients treated with fluoroquinolones (50 patients with levofloxacin and 4 patients with ofloxacin). Results No significant differences were seen between the two groups regarding age, sex, smoking, alcohol intake, underlying diseases, or community/hospital acquisition. The time from onset of LD symptoms until the initiation of antibiotic treatment was 78.5 h and 92.7 h in groups 1 and 2, respectively (p = 0.1). Time to apyrexia was significantly longer in the macrolide group (77.1 h vs 48 h for groups 1 and 2, respectively; p=0.000). There were no differences according to radiology, clinical complications, or mortality. Nevertheless, a trend to a longer hospital stay was observed in the macrolide group (9.9 days vs 7.6 days in groups 1 and 2, respectively; p=0.09). Conclusions Fluoroquinolones were as effective as erythromycin in the treatment of LD. It is of note that time to apyrexia was significantly shorter and hospital stay tended to be shorter in patients receiving fluoroquinolones.

Study objective To know the incidence, epidemiology, etiology, and outcome of hospital-acquired pneumonia (HAP) in non-ICUs adult patients. Setting Twelve Spanish teaching hospitals. Interventions From April 1999 to November 2000, non-ICU HAP was prospectively studied by active, bimonthly 1-week surveillance. Epidemiologic data, etiology, and evolution of pneumonia were recorded. Blood and sputum cultures and Legionella pneumophila and Streptococcus pneumoniae urinary antigen tests were performed. Results We included 186 patients, with complete data available in 165 patients (70.3% male gender; mean age, 63.7 ± 16.9 years [ ± SD]) The mean incidence of HAP was 3 ± 1.4 cases/1,000 hospital admissions. Most patients (64.2%) were in medical wards, had severe underlying diseases (66.6%), and had a hospital stay > 5 days (76.4%). Blood cultures were performed in 139 patients (84.2%), sputum cultures were performed in 89 patients (53.9%), and urinary antigen detection was performed in 123 patients (74.5%). An etiologic diagnosis was obtained in 60 cases (36.4%), and 31 were definitive. The most frequent etiologies were S pneumoniae (16 cases, 14 definitive), L pneumophila (7 cases, 7 definitive), Aspergillus sp (7 cases, 3 definitive), Pseudomonas aeruginosa (7 cases, 2 definitive), and several Enterobacteriaceae (8 cases, 4 definitive). Clinical complications occurred in 52.1% of the cases, and mortality was 26% (13.9% attributed to pneumonia). Conclusions Non-ICU HAP is an important cause of hospital morbidity, observed most frequently in medical wards and elderly patients with severe underlying diseases. In this setting, S pneumoniae and Legionella sp should be considered in addition to other nosocomial pathogens; urinary antigen detection is useful in determining the prevalence of these microorganisms.

Study objectives To compare the outcome of Legionnaires disease (LD) in patients with and without HIV infection. Design Retrospective review of clinical charts. Setting Six hundred-bed university hospital. Patients We studied the clinical findings of 64 patients without HIV and 15 patients with HIV. Patients with a serologic diagnosis only were not included. Patients with previous immunosuppressive therapy or transplant recipients were excluded from the former group. In the HIV group, the mean CD4 cell count was 347.5/μL, plasma viral load was undetectable in 50% of the patients, and only one patient (7%) was receiving cotrimoxazole as prophylaxis against Pneumocystis carinii at the time of pneumonia. No differences were observed in the two groups with respect to community or nosocomial acquisition, delay in the initiation of appropriate treatment, the use of macrolides or fluoroquinolones, and Fine score in cases of community-acquired LD. Results Univariate analysis showed that time to apyrexia was longer, and respiratory symptoms, bilateral infiltrates in chest radiograph, hyponatremia, increase in aspartate aminotransferase and creatine phosphokinase (CK), and respiratory failure were more frequent in the HIV group. Mortality was greater in patients with HIV, achieving a statistically significant value of 20%; however, multivariate analysis only confirmed these differences with respect to the increase in CK. Conclusions LD has a more severe clinical presentation and worse evolution in patients with HIV.

Las infecciones relacionadas con la asistencia sanitaria constituyen uno de los mayores desafios de la medicina moderna. Segun el Estudio de Prevalencia de la Infeccion Nosocomial en Espana (EPINE) del ano 2010, un 6,7% de los pacientes atendidos en los hospitales presentaron una infeccion nosocomial. Por otro lado, el estudio de la seguridad de los pacientes en atencion primaria (APEAS) de 2008 mostro que un 7% presentaro algun evento adverso, siendo un 8,4% de estos infecciones relacionadas con la atencion sanitaria. Las manos de los profesionales sanitarios son la via principal de transmision de los microorganismos causantes de infecciones en el ambito de la salud. En consecuencia, la higiene de manos (HM) es la medida mas sencilla, barata y eficaz para prevenir las infecciones relacionadas con la atencion sanitaria y la diseminacion de patogenos resistentes a los antibioticos. Sin embargo, el grado de adherencia a esta medida es inaceptablemente bajo. Los estudios observacionales realizados en numerosos hospitales muestran que la HM se realiza en menos del 50% de las ocasiones en que esta indicada. Los principales factores limitantes son la carga de trabajo, la poca accesibilidad de los lavamanos, el uso de guantes y la irritacion de las manos. Los estudios realizados en otros ambitos asistenciales tambien muestran tasas de cumplimiento muy bajas: 17,5% en un centro de larga estancia y 8,1% en un area de atencion primaria de Madrid. El conocimiento por parte del personal sanitario del mecanismo de contaminacion de las manos y de la importancia de la HM en la prevencion de las infecciones nosocomiales es fundamental para mejorar la adherencia a esta medida. Los microorganismos potencialmente patogenos se encuentran presentes en la piel del paciente y en las superficies de su entorno. Las manos del personal sanitario se contaminan con dichos microorganismos, la denominada flora transitoria, por contacto directo o indirecto. La HM tiene como objeto eliminar dicha flora transitoria y evitar la transmision cruzada entre pacientes. La tecnica de HM ideal deberia ser rapida, eficaz en reducir la colonizacion bacteriana y bien tolerada por la piel. Existen 2 procedimientos: el lavado de las manos con agua y jabon, y la friccion con una solucion alcoholica. El lavado de las manos actua mediante el arrastre de particulas por la friccion y el efecto

Legionella pneumophila has been recognized as an important cause of community-and hospital-acquired pneumonia in both healthy and immunosuppressed patients since its first description in 1976. The authors have systematically used urinary antigen testing as a specific diagnostic test for Legionella infection since 1994. It should also be pointed out that the reporting of Legionnaires’ disease (LD) has been mandatory in Catalonia since 1987. This chapter describes demographic data; clinical, analytical, and radiological characteristics; diagnostic methods; and therapeutic data of a series of community- and hospital-acquired cases of LD collected from 1983 to 2005. It determines trends in demographic and clinical data, individual risk factors, diagnostic methods, and outcome over time. Mortality by nosocomial and community-acquired LD combined has almost significantly decreased over time, which may be due to the earlier diagnosis and changes in treatment.

This chapter compares the individual risk factors, clinical features, and mortality of Legionella pneumonia in hospital and community scenarios. A comparative study was performed from 1983 to 2005, with 425 cases of pneumonia due to Legionella pneumophila being diagnosed during this time. The patients were divided into two groups based on the site of acquisition. Group 1 included 197 patients with community-acquired Legionella pneumonia (CALP), and group 2 included 123 patients with hospital-acquired Legionella pneumonia (HALP). Respiratory symptoms, gastrointestinal, neurological manifestations, and laboratory abnormalities prevailed in the community setting probably for two reasons: first, the CALP patients entered the hospital late because of the lack of specificity in initial symptomatology, allowing extrapulmonary symptoms to develop. Second, in hospitals with endemic legionellosis, the diagnosis and the onset of treatment for nosocomial Legionella pneumonia is immediate because of the high level of suspicion. This makes the extrapulmonary manifestations of Legionella infection less likely to be observed. The best way to prevent HALP is by culturing the hospital water supply, and, if colonized, Legionella tests should be used in any case of hospital-acquired pneumonia.

Bacterial pneumonia continues to be the most frequent pulmonary complication in human immunodeficiency virus (HIV)-infected patients, although its prevalence has decreased with the use of highly active antiretroviral therapy. The most common etiologic agent of community-acquired pneumonia (CAP) in infected and uninfected patients is Streptococcus pneumoniae. Legionella is at present one of the leading causes of CAP in the general population. This chapter compares the epidemiological data, clinical features, outcome, and mortality of pneumonia by S. pneumoniae and by Legionella spp. in HIV-infected patients. An observational, comparative study was performed in 15 HIV patients with CAP by Legionella (group 1) and 46 by S. pneumoniae (group 2). No statistically significant differences were observed between the two groups in either the use of an appropriate antibiotic treatment in the emergency department or in the delay from the presentation of the symptoms until the initiation of an appropriate antibiotic therapy. Legionella pneumonia (LP) should be considered as an opportunistic infection in HIV-infected patients, and the Legionella urinary antigen test should be mandatory whenever we are faced with CAP in an HIV-positive patient.

Colonization of cooling towers (CTs) by Legionella is frequent and has been implicated in many community outbreaks of Legionnaires´ disease (LD). This chapter describes the fluctuation in Legionella counts in CTs over a 1-year period. Ten colonies of each positive culture were selected and characterized by nutritional requirements and by the immunoglutination latex assay test (OXOID). Legionella pneumophila was isolated in 13 of 15 CTs (86.6%). All positive CTs were colonized by L. pneumophila serogroup 1. No seasonal influence was observed with respect to variations in L. pneumophila counts. All of the systems would not have been considered a risk at some sample time during the same season.

Legionella pneumophila has frequently been found in cooling towers (CT) with different DNA subtypes being implicated in community-acquired Legionella infections. The aims of this chapter were to investigate the genotypic variability of L. pneumophila in cooling towers and determine the persistence of the DNA subtypes over time in two different areas. In six cooling towers the authors observed a single DNA subtype, in five, two DNA subtypes, in three cooling towers, three DNA subtypes and in two cooling towers the authors observed fewer than four DNA subtypes. In three of the seven cooling towers the authors observed a single DNA subtype, in two the authors found two DNA subtypes, and in another two, three DNA subtypes were reported. When authors studied the persistence of the DNA subtypes it was found that in 19 of 23 cooling towers (82%) the same DNA subtype was recovered after at least 6 months of follow-up. These results demonstrate the great genotypic variability of Legionella in the cooling towers.

This chapter determines variables related to mortality of Legionnaire's disease (LD). An observational, comparative study was performed from 1983 to 2005, with 408 cases of Legionella pneumonia being diagnosed during this time. The variables studied included demographic characteristics, individual and aspiration risk factors, clinical manifestations, radiological manifestations, diagnostic data, treatment, and outcome. The variables were analyzed using univariate and multivariate logistic regression analysis by SPSS version 12.0. Regarding demographic data and risk factors, patients who died had a higher frequency of underlying diseases than the control group (89.8 versus 66.9%): mainly chronic respiratory disease (42.9 versus 29.6%), chronic heart failure (22.4 versus 10.2%), neoplasm (38.8 versus 15.8%), neurological sequelae (20 versus 7.6%), and inmunosuppressive therapy-mainly corticoids (45.8 versus 14.6%). Despite the improvement in the diagnostic procedures of LD and the use of more efficacious antibiotics against Legionella, chronic heart failure, hematological cancer, and corticotherapy are still bad prognostic factors of LD. Recommendations for prevention of LD should focus on settings in which there are persons at greatest risk for illness or serious outcome.

This chapter determines the prevalence of Legionella spp. and identifies the chromosomal DNA subtypes and the genomic stability of these isolates during a 20-month follow-up period in the potable-water distribution system of a hotel. From June 2003 to March 2005, 110 water samples were collected from a hotel water supply comprising 11 sample collections of water. Legionella pneumophila serogroup (sg.) 1 was isolated in 49 (44.55%) of the 110 samples tested. The cold water distal point was L. pneumophila–positive throughout the whole study period. It should be pointed out that this distal point of cold water was an infrequently used point (roof-top tap) with stagnant water, which may explain the low chlorine levels (range, 0.05 to 0.95 mg of Cl2 per liter), the heating of water during warmer seasons and thus, colonization by Legionella throughout the study period. Environmental isolates of Legionella were genotypically characterized by pulsed-field gel electrophoresis. The number of colonized points was uniform throughout the 20-month study. All L. pneumophila isolates analyzed showed the same chomosomal DNA genotype, which indicated the clone stability over the 20-month follow-up period.

Objective:To investigate the presence and clonal distribution ofLegionellaspecies in the water supply of 20 hospitals in Catalonia, Spain.Setting:20 hospitals in Catalonia, an area of 32,000 km2, located in northeast Spain.Methods:Environmental cultures of 186 points of potable water supply and 10 cooling towers were performed for the presence ofLegionellaspecies. Following filtration and acid treatment, the samples were seeded in selective MWY (modified Wadowsky Yee)-buffered charcoal yeast extract-a agar. All isolates obtained were characterized microbiologically and genotyped bySfilpulsed-field gel electrophoresis (PFGE).Results:73 of 196 water samples, representing 17 of the 20 hospitals included in the study, were positive forLegionella pneumophila(serogroups 1, 2-14, or both). The degree of contamination ranged from 200 to 74,250 colony-forming units/L. Twenty-five chromosomal DNA subtypes were detected by PFGE. A single DNA subtype was identified in 10 hospitals, 2 DNA subtypes were observed in 6 hospitals, and 1 hospital exhibited 3 different DNA subtypes. Each hospital had its ownLegionellaDNA subtype, which was not shared with any other hospitals.Conclusions:Legionellawas present in the water of most of the hospitals studied; each such hospital had a unique, dominant chromosomal DNA subtype. The verification of several genomic DNA restriction profiles in such a small geographic area demonstrates the great genetic diversity ofLegionellain the aquatic environment.

Since 1990 a clone of gentamicin and methicillin-resistant Staphylococcus aureus (MRSA) has remained endemic in our hospital, but since January 1996 a gentamicin-sensitive strain has progressively replaced the previous clone. We characterized the phenotypic and molecular pattern of the MRSA strains isolated in our hospital in 1996 and compared prospectively the epidemiological, clinical and evolutionary characteristics of ninety patients infected or colonized by gentamicin-sensitive MRSA (GS-MRSA) (49) and by gentamicin-resistant MRSA (GR-MRSA) (41). Finally we studied the variation of aminoglycoside consumption in our hospital from 1989 to 1996. We observed two antibiotypes (GS-MRSA and GR-MRSA) corresponding to two major chromosomal patterns. Patients with GS-MRSA usually acquired the infection 72 hours after hospital admission. No significant differences were observed in epidemiological characteristics, clinical presentation and evolution between patients with GS-MRSA and GR-MRSA. Since 1989 aminoglycoside intake in our hospital has decreased by 46%.

Study objectives To prospectively assess the relative risk for phlebitis in a series of consecutive patients with pneumonia and to identify risk factors that predict an increased risk for phlebitis. Setting Internal medicine department of a tertiary teaching hospital. Patients Seven hundred sixty-six consecutive patients with acute pneumonia receiving IV therapy. Interventions Only the first catheter was taken into account. There were 308 short lines (a 51-mm, 18-gauge Teflon catheter); 307 midsized lines (a 28-cm, 16-gauge polyvinyl chloride catheter); and 151 long lines (71-cm, 14-gauge plain polyurethane catheter). Eighteen variables were prospectively evaluated in an open, nonrandomized study for their contribution to the occurrence of phlebitis. Results The overall phlebitis rate was 39%. Phlebitis developed in 53% of patients with short lines, in 41% of patients with midsized lines, and in 10% of patients with long lines, and these catheters remained in place an average (± SD) of 3.0 ± 2.4 days, 4.6 ± 3.4 days, and 7.8 ± 6.6 days, respectively. The variables that influenced the development of phlebitis, as determined by multivariate analysis, were the following: type of catheter; blood hemoglobin levels; and IV therapy with either corticosteroids or erythromycin. Conclusions According to our data, when the use of a catheter is expected to be required for ≤ 36 h, a short line can be used. If a longer duration is expected, a longer line is warranted. Ours is the first study in which the relationship between blood hemoglobin levels and phlebitis has been reported. Because the use of intravascular devices is increasingly common, a more complete knowledge of the factors that influence their acceptance has become essential.

The concentrations of Legionella pneumophila in cooling towers may vary considerably over short periods of time, producing significant fluctuations throughout the year. Despite genetic variability, in small geographical areas the same indistinguishable pulsed-field gel electrophoresis patterns may be shared among different cooling towers and persist over time.

Copper and silver ionization is a well-recognized disinfection method to control Legionella species in water distribution systems in hospitals. These systems may also serve as a potential indoor reservoir for fungi. The prevalence of fungi was significantly lower in ionized than in nonionized water samples from health care facilities. The clinical consequences of this finding require further investigation.

The aim of this study was to compare the clinical, biological, and radiologic features of presentation in the emergency ward of community-acquired pneumonia (CAP) by Legionella pneumophila (LP) and other community-acquired bacterial pneumonias to help in early diagnosis of CAP by LP. Three hundred ninety-two patients with CAP were studied prospectively in the emergency department of a 600-bed university hospital. Univariate and multivariate analyses were performed to compare epidemiologic and demographic data and clinical, analytical, and radiologic features of presentation in 48 patients with CAP by LP and 125 patients with CAP by other bacterial etiology (68 by Streptococcus pneumoniae, 41 by Chlamydia pneumoniae, 5 by Mycoplasma pneumoniae, 4 by Coxiella burnetii, 3 by Pseudomonas aeruginosa, 2 by Haemophilus influenzae, and 2 by Nocardia species. Univariate analysis showed that CAP by LP was more frequent in middle-aged, male healthy (but alcohol drinking) patients than CAP by other etiology. Moreover, the lack of response to previous beta-lactamic drugs, headache, diarrhea, severe hyponatremia, and elevation in serum creatine kinase (CK) levels on presentation were more frequent in CAP by LP, while cough, expectoration, and thoracic pain were more frequent in CAP by other bacterial etiology. However, multivariate analysis only confirmed these differences with respect to lack of underlying disease, diarrhea, and elevation in the CK level. We conclude that detailed analysis of features of presentation of CAP allows suspicion of Legionnaire's disease in the emergency department. The initiation of antibiotic treatment, including a macrolide, and the performance of rapid diagnostic techniques are mandatory in these cases.

Fluoroquinolones are the most active drugs against Legionella in intracellular and animal models, achieving high intracellular levels and low MICs. In patients with human immunodeficiency virus infection, Legionnaires' disease (LD) has a more severe clinical presentation and worse evolution, with a mortality rate of up to 20%. This chapter presents a case of a severely inmunosuppressed woman with LD in whom treatment failed with levofloxacin and who recovered after the addition of azithromycin. The intracellular location of the pathogen is relevant to the efficacy of the antibiotic. At present, new macrolides such as clarithromycin and azithromycin and fluoroquinolones are the most active drugs in the treatment of Legionella pneumonia. Even though the advances in rapid specific diagnosis and the greater efficacy of the new macrolides and quinolones have led to a better prognosis of Legionella pneumonia, mortality continues to be very high in immunosuppressed patients. Thus, randomized trials comparing the efficacy of combination therapies with new macrolides and quinolones versus monotherapy should be performed to evaluate their real impact in reducing morbidity and mortality of Legionella pneumonia with bad prognostic factors.

Fundamento y objetivo El choque termico es un metodo de desinfeccion frente a Legionella en circuitos de agua sanitaria. En enero de 1996 se produjo un brote de legionelosis nosocomial (LN) en el Hospital Germans Trias i Pujol. El objetivo de este estudio fue evaluar el impacto ambiental y clinico de un choque termico. Material y metodo Recogida diaria de muestras de agua de puntos centrales y de consumo 3 dias antes del choque termico y los 15 dias posteriores. Vigilancia clinica de LN durante 30 dias consecutivos tras el choque termico. Resultados Tras el choque termico, el inoculo de Legionella pneumophila en puntos centrales disminuyo, pero aumento a partir del dia 11 y alcanzo su valor maximo a los 15 dias. No se detecto L. pneumophila en puntos de consumo a los 4 dias. Sin embargo, a partir del dia 7, hubo recolonizacion, que alcanzo el 66% el dia 9. No se detectaron casos clinicos de LN durante el periodo de estudio. Conclusiones El choque termico es un metodo de desinfeccion, eficaz pero transitorio, que permite actuar de forma inmediata ante un brote de LN.

Background Hospital-acquired pneumonia (HAP) is one of the leading nosocomial infections and is associated with high morbidity and mortality. Numerous studies on HAP have been performed in intensive care units (ICUs), whereas very few have focused on patients in general wards. This study examined the incidence of, risk factors for, and outcomes of HAP outside the ICU. Methods An incident case-control study was conducted in a 600-bed hospital between January 2006 and April 2008. Each case of HAP was randomly matched with 2 paired controls. Data on risk factors, patient characteristics, and outcomes were collected. Results The study group comprised 119 patients with HAP and 238 controls. The incidence of HAP outside the ICU was 2.45 cases per 1,000 discharges. Multivariate analysis identified malnutrition, chronic renal failure, anemia, depression of consciousness, Charlson comorbidity index ≥3, previous hospitalization, and thoracic surgery as significant risk factors for HAP. Complications occurred in 57.1% patients. The mortality attributed to HAP was 27.7%. Conclusions HAP outside the ICU prevailed in patients with malnutrition, chronic renal failure, anemia, depression of consciousness, comorbidity, recent hospitalization, and thoracic surgery. HAP in general wards carries an elevated morbidity and mortality and is associated with increased length of hospital stay and increased rate of discharge to a skilled nursing facility.