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

Purpose: Inappropriate use of antibiotics is an important health problem that is related to increasing bacterial resistance. Despite its relevance, many health institutions assign very limited resources to improving prescribing practices. An antimicrobial stewardship programme (APS) centred on patients discharged from the ICU could efficiently undertake this task., Methods: During this six month study the main activity was performing a programmed review of antimicrobial prescriptions in patients transferred to the ward from the ICU. In the case of inadequate antimicrobial treatment, a recommendation was included in the medical record., Results: A total of 437 antimicrobial prescriptions for 286 patients were revised during a six month period. In all, 271 prescriptions (62%) were considered inappropriate in 183 patients. The most common reasons for inappropriateness were treating unconfirmed infection (43%), inadequate antimicrobial coverage (34%) and intravenous administration when the oral route was feasible (11%). Proposed recommendations were addressed in 212 cases (78%). There was no significant difference in adherence with respect to the type of recommendation (p=0.417). There was a 5% lower use of antibiotics during the year the study was conducted compared to the previous one., Conclusions: ASPs centred on patients discharged from the ICU may be an efficient strategy to ameliorate antimicrobial use in hospitals.

Background: The aim of this study was to assess the efficacy of tigecycline in the treatment of infections due to carbapenemase-producing Klebsiella pneumoniae (CPKP) in critically ill patients., Methods: A retrospective observational study was conducted in critically ill patients receiving different tigecycline doses for severe CPKP infections. We evaluated demographic data, localization and severity of infection, response to therapy, and mortality., Results: Fifteen patients received tigecycline for 16 episodes of CPKP infection. The main infections were pneumonia (31%), urinary tract infection (31%), peritonitis (20%), catheter-related bacteraemia (12%), and meningitis (6%). Most infections were complicated with severe sepsis (44%), septic shock (12%), and/or bacteraemia (19%). The daily maintenance dose of tigecycline was 200 mg in 10 episodes and 100 mg in 6 episodes. The overall 30-day mortality rate was 25%. Univariate analysis showed that mortality was significantly associated (p < 0.01) with mean APACHE II and SOFA scores and the presence of immunosuppression, but not with the tigecycline dose., Conclusions: Tigecycline appears to be an effective therapy for severe infections due to CPKP in critically ill patients. Mortality is related to the severity of the underlying disease. We observed no benefit from a higher maintenance dose of tigecycline, although the number of patients included in the study was too small to draw any general conclusions in this regard.

We study the epidemiology, molecular basis, clinical risk factors, and outcome involved in the clonal dissemination of VIM-1-producing Klebsiella pneumoniae isolates in the hospital setting. All patients infected/colonized by carbapenem-nonsusceptible K. pneumoniae (CNSKP) in 2009 were included. Molecular epidemiology was studied by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Antibiotic resistance genes were analyzed by PCR and sequencing. Plasmids were studied by PFGE with S1 nuclease digestion and for incompatibility group by a PCR-based replicon typing scheme. Risk factors associated with CNSKP colonization/infection were assessed by an observational case-control study. All 55 patients studied were infected (n = 28) or colonized (n = 27) by VIM-1-producing K. pneumoniae. All but one acquired isolates of a single clone (PFGE cluster 1 [C1], sequence type 15 [ST15]), while another clone (PFGE C2, ST340) was detected in four patients. C1 isolates also produced the new extended-spectrum β-lactamase SHV-134. bla(VIM-1) was carried in a class 1 integron and an untypeable plasmid of ∼50 bp. The number of days that the patient received mechanical ventilation, the use of parenteral nutrition, previous treatment with linezolid, and treatment with extended-spectrum cephalosporins for more than 7 days were detected to be independent risk factors for CNSKP acquisition. The VIM-1-producing K. pneumoniae ST15 clone has a high capacity to spread among intensive care unit patients with severe underlying conditions. A high rate of associated mortality and great difficulty in controlling the spread of this clone, without permanent behavioral changes in the personnel, were observed.

Introduction: This study aims to evaluate the prognosis of urinary tract infections (UTI) treated empirically with inadequate antibiotic treatment., Material and Methods: Prospective cohort study of patients over 18 years of age, attended in the hospital emergency service between 01/02 and 31/05 of 2007, due to micturation symptoms, accompanied by pyuria (>10 leukocytes/mm(3) of uncentrifuged urine) or positive reactive strip for nitrites-leukocytes and urine culture with >10(3) colony forming units. It was considered that the antibiotic treatment prescribed empirically was adequate if the bacteria isolated was sensitive and had been prescribed for the correct time. It was considered that there was therapeutic failure when the symptoms persisted after 5 days of treatment. Age, gender, presence of indwelling bladder catheter, type of UTI, hospitalization in the previous 3 months, origin of the patient and associated diseases were recorded., Results: A total of 177 bacteria were isolated in 168 patients. In 29 cases (17.3%), the microorganism isolated was resistant to the antibiotic prescribed. There was thereaputic failure in only 6 patients, although they did not required hospital admission. The patients who lived in a residential home for the elderly (13.7% vs 2.2%, P = 0.015) or who had been hospitalized during the previous 3 months (20.6% vs 4.3%, p = 0.039) had a greater risk of receiving inadequate treatment., Conclusions: The prognosis of the patients attended in the emergency hospital service due to UTI with discordant antibiotic treatment is favorable in most of the cases. Performing urine culture in patients with greater risk of suffering UTI due to a resistant microorganism would be recommendable., (Copyright © 2009 Elsevier España, S.L. All rights reserved.)