Publications by authors named "Mercedes Palomar"

39 Publications

A clinical evaluation of two central venous catheter stabilization systems.

Ann Intensive Care 2019 Apr 17;9(1):49. Epub 2019 Apr 17.

Corporate Division, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK.

Background: Central venous catheters (CVCs) are commonly secured with sutures which are associated with microbial colonization and infection. We report a comparison of a suture-free system with standard sutures for securing short-term CVC in an international multicentre, prospective, randomized, non-blinded, observational feasibility study. Consented critical care patients who had a CVC inserted as part of their clinical management were randomized to receive either sutures or the suture-free system to secure their CVC. The main outcome measures were CVC migration (daily measurement of catheter movement) and unplanned catheter removals.

Results: The per cent of unplanned CVC removal in the two study groups was 2% (suture group 2 out of 86 patients) and 6% (suture-free group 5 out of 85 patients). Both securement methods were well tolerated in terms of skin irritation. The time and ease of application and removal of either securement systems were not rated significantly different. There was also no significant difference in CVC migration between the two securement systems in exploratory univariate and multivariate analyses. Overall, 42% (36 out of 86) of the CVC secured with sutures and 56% (48 out of 85) of the CVC secured with the suture-free securement system had CVC migration of ≥ 2 mm.

Conclusions: The two securement systems performed similarly in terms of CVC migration and unplanned removal of CVC; however, the feasibility study was not powered to detect statistically significant differences in these two parameters.

Trial Registration: ISRCTN, ISRCTN13939744. Registered 9 July 2015, http://www.isrctn.com/ISRCTN13939744 .
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http://dx.doi.org/10.1186/s13613-019-0519-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470223PMC
April 2019

Quality of the aetiological diagnosis of ventilator-associated pneumonia in Spain in the opinion of intensive care specialists and microbiologists.

Enferm Infecc Microbiol Clin 2017 Mar 13;35(3):153-164. Epub 2016 Oct 13.

Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain. Electronic address:

Introduction: Current guidelines for the microbiological diagnosis of ventilator-associated pneumonia (VAP) are imprecise. Based on data provided by intensive care specialists (ICS) and microbiologists, this study defines the clinical practices and microbiological techniques currently used for an aetiological diagnosis of VAP and pinpoints deficiencies.

Methods: Eighty hospitals in the national health network with intensive care and microbiology departments were sent two questionnaires, one for each department, in order to collect data on VAP diagnosis for the previous year.

Results: Out of the 80 hospitals, 35 (43.8%) hospitals participated. These included 673 ICU beds, 32,020 ICU admissions, 173,820 ICU days stay, and generated 27,048 lower respiratory tract specimens in the year. A third of the hospitals (35%) had a microbiology department available 24/7. Most samples (83%) were tracheal aspirates. Gram stain results were immediately reported in around half (47%) of the hospitals. Quantification was made in 75% of hospitals. Molecular techniques and direct susceptibility testing were performed in 12% and one institution, respectively. Mean turnaround time for a microbiological report was 1.7 (SD; 0.7), and 2.2 (SD; 0.6) days for a negative and positive result, respectively. Telephone/in-person information was offered by 65% of the hospitals. Most (89%) ICS considered microbiological information as very useful. No written procedures were available in half the ICUs.

Conclusions: Both ICS and microbiologists agreed that present guidelines for the diagnosis of VAP could be much improved, and that a new set of consensus guidelines is urgently required. A need for guidelines to be more effectively implemented was also identified in order to improve outcomes in patients with VAP.
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http://dx.doi.org/10.1016/j.eimc.2016.08.009DOI Listing
March 2017

Consumption of systemic antifungal agents among acute care hospitals in Catalonia (Spain), 2008-2013.

Expert Rev Anti Infect Ther 2016 14;14(1):137-44. Epub 2015 Oct 14.

Director of VINCat Program, VINCat Coordinating Centre, Department of Health, Catalonia, Barcelona, Spain.

Objective To know the patterns and consumption trends (2008-2013) of antifungal agents for systemic use in 52 acute care hospitals affiliated to VINCat Program in Catalonia (Spain). Methods Consumption was calculated in defined daily doses (DDD)/100 patient-days and analyzed according to hospital size and complexity and clinical departments. Results Antifungal consumption was higher in intensive care units (ICU) (14.79) than in medical (3.08) and surgical departments (1.19). Fluconazole was the most consumed agent in all type of hospitals and departments. Overall antifungal consumption increased by 20.5%during the study period (p = 0.066); a significant upward trend was observed in the consumption of both azoles and echinocandins. In ICUs, antifungal consumption increased by 12.4% (p = 0.019). Conclusions The study showed a sustained increase in the overall consumption of systemic antifungals in a large number of acute care hospitals of different characteristics in Catalonia. In ICUs there was a trend towards the substitution of older agents by the new ones.
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http://dx.doi.org/10.1586/14787210.2016.1096776DOI Listing
October 2016

Diagnosis and treatment of bacteremia and endocarditis due to Staphylococcus aureus. A clinical guideline from the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC).

Enferm Infecc Microbiol Clin 2015 Nov 1;33(9):625.e1-625.e23. Epub 2015 May 1.

Servicio de Cuidados Intensivos, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain.

Both bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. The prognosis may darken not infrequently, especially in the presence of intracardiac devices or methicillin-resistance. Indeed, the optimization of the antimicrobial therapy is a key step in the outcome of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates has led to the research of novel therapeutic schemes. Specifically, the interest raised in recent years on the new antimicrobials with activity against methicillin-resistant staphylococci has been also extended to infections caused by susceptible strains, which still carry the most important burden of infection. Recent clinical and experimental research has focused in the activity of new combinations of antimicrobials, their indication and role still being debatable. Also, the impact of an appropriate empirical antimicrobial treatment has acquired relevance in recent years. Finally, it is noteworthy the impact of the implementation of a systematic bundle of measures for improving the outcome. The aim of this clinical guideline is to provide an ensemble of recommendations in order to improve the treatment and prognosis of bacteremia and infective endocarditis caused by S. aureus, in accordance to the latest evidence published.
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http://dx.doi.org/10.1016/j.eimc.2015.03.015DOI Listing
November 2015

Executive summary of the diagnosis and treatment of bacteremia and endocarditis due to Staphylococcus aureus. A clinical guideline from the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC).

Enferm Infecc Microbiol Clin 2015 Nov 30;33(9):626-32. Epub 2015 Apr 30.

Servicio de Cuidados Intensivos, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain.

Bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. Optimization of treatment is fundamental in the prognosis of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates have led to research on novel therapeutic schemes. The interest in the new antimicrobials with activity against methicillin-resistant staphylococci has been extended to susceptible strains, which still carry the most important burden of infection. New combinations of antimicrobials have been investigated in experimental and clinical studies, but their role is still being debated. Also, the appropriateness of the initial empirical therapy has acquired relevance in recent years. The aim of this guideline is to update the 2009 guidelines and to provide an ensemble of recommendations in order to improve the treatment of staphylococcal bacteremia and infective endocarditis, in accordance with the latest published evidence.
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http://dx.doi.org/10.1016/j.eimc.2015.03.014DOI Listing
November 2015

[Empirical antimicrobial therapy in ICU admitted patients. Influence of microbiological confirmation on the length of treatment].

Rev Esp Quimioter 2014 Dec;27(4):252-60

Xavier Nuvials, Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Av. Rovira Roure 80. 25198. Lleida, Spain.

Introduction. Most patients admitted to the Intensive Care Units (ICU) receive antimicrobial treatment. A proper therapeutic strategy may be useful in decreasing inappropriate empirical antibiotic treatments. When the infection is not microbiologically confirmed, the antimicrobial streamlining may be difficult. Nevertheless, there is scant information about the influence of the microbiological confirmation of the infections on empirical antimicrobial treatment duration. Method. Post-hoc analysis of prospective data (ENVIN-UCI register) and observational study of patients admitted (> 24 hours) in a medico-surgical ICU, through the three-months annual surveillance interval for a period of ten years, receiving antimicrobial treatment for treating an infection. Demographic, infection and microbiological data were collected as well as empirical antimicrobial treatment and causes of adaptation. The main goal was to establish the influence of microbiological confirmation on empirical antimicrobial treatment duration. Results. During the study period 1,526 patients were included, 1,260 infections were diagnosed and an empirical antibiotic treatment was started in 1,754 cases. Infections were microbiologically confirmed in 1,073 (62.2%) of the empirical antibiotic treatment. In 593 (55.3%) cases, the antimicrobial treatment was considered appropriate. The main cause of treatment adaptation in the microbiologically confirmed infections was streamlining (39%). The microbiological confirmation of the infection was not associated with significantly shorter empirical antibiotic treatments (6.6 ± 5.2 VS. 6.8 ± 4.5 days). Conclusion. The microbiological confirmation of infections in patients admitted to UCI was associated with a higher reduction of antimicrobial spectrum, although had no effect on the length of empirical antimicrobial therapy.
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December 2014

[Results of the implementation of the Bacteremia Zero project in Catalonia, Spain].

Med Clin (Barc) 2014 Jul;143 Suppl 1:11-6

Servicio de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Lleida, España.

The nationwide Bacteremia Zero (BZ) Project consists in the simultaneous implementation of measures to prevent central venous catheter-related bacteremia (CVC-B) in critically ill patients and in the development of an integral safety plan. The objective is to present the results obtained after the implementation of the BZ project in the ICUs of the Autonomous Community of Catalonia, Spain. All patients admitted to ICUs in Catalonia participating in the ENVIN-HELICS registry between January 2009 and June 2010 were included. Information was provided by 36 (92.3%) of the total possible 39 ICUs. A total of 281 episodes of CVC-B were diagnosed (overall rate of 2.53 episodes per 1000 days of CVC). The rates have varied significantly between ICUs that participated in the project for more or less than 12 months (2.17 vs. 4.27 episodes per 1000 days of CVC, respectively; p<.0001). The implementation of the BZ Project in Catalonia has been associated with a decrease greater than 40% in the CVC-B rates in the ICUs of this community, which is much higher than the initial objective of 4 episodes per 1000 days of CVC).
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http://dx.doi.org/10.1016/j.medcli.2014.07.006DOI Listing
July 2014

The authors reply.

Crit Care Med 2014 May;42(5):e384-5

Intensive Care Unit, Hospital Universitario Arnau de Vilanova IRB Lleida, Universitat Autónoma de Barcelona, Barcelona, Spain Intensive Care Unit, Parc de Salud Mar, Universitat Autónoma de Barcelona, Barcelona, Spain Quality Agency of the National Health System, Spanish Ministry of Health, Madrid, Spain.

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http://dx.doi.org/10.1097/CCM.0000000000000233DOI Listing
May 2014

The authors reply.

Crit Care Med 2014 May;42(5):e382-3

Intensive Care Department, Hospital Universitario Arnau de Vilanova IRB Lleida, Universitat Autônoma de Barcelona, Barcelona, Spain; Intensive Care Unit, Parc de Salud Mar, Universitat Autónoma de Barcelona, Barcelona, Spain; Quality Agency of the National Health System, Spanish Ministry of Health, Madrid, Spain.

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http://dx.doi.org/10.1097/CCM.0000000000000234DOI Listing
May 2014

Preventable proportion of severe infections acquired in intensive care units: case-mix adjusted estimations from patient-based surveillance data.

Infect Control Hosp Epidemiol 2014 May 24;35(5):494-501. Epub 2014 Mar 24.

Healthcare Associated Infections Unit, Scientific Institute of Public Health, Brussels, Belgium.

Background: More than 10% of patients admitted to intensive care units (ICUs) experience a severe, healthcare-associated infection, such as ventilator-associated pneumonia (VAP) or bloodstream infection (BSI). What could be a public health target for prevention is hotly debated, because properly adjusting for intrinsic risk factors in the patient population is difficult. We aimed to estimate the proportion of ICU-acquired VAP and BSI cases that are amenable to prevention in routine conditions.

Methods: We analyzed routine data collected prospectively according to the European standard protocol for patient-based surveillance of healthcare-acquired infections in ICUs. We computed the number of infections to be expected if, after adjustment for case mix, the infection incidence in ICUs with higher infection rates could be reduced to that of the top-tenth-percentile-ranked ICU. Computations came from model-based simulation of individual patient profiles over time in the ICU. The preventable proportion was computed as the number of observed cases minus the number of expected cases divided by the number of observed cases.

Results: Data for 78,222 patients admitted for more than 2 days to 525 ICUs in 6 European countries from 2005 to 2008 were available for analysis. We calculated that 52% of VAP and 69% of BSI was preventable.

Conclusions: Our pragmatic, if highly conservative, estimates quantify the potential for prevention of VAP and BSI in routine conditions, assuming that variation in infection incidence between ICUs can be eliminated with improved quality of care, apart from variation attributable to differential case mix.
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http://dx.doi.org/10.1086/675824DOI Listing
May 2014

The authors reply.

Crit Care Med 2014 Feb;42(2):e171-2

ICU Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain; UAB, Barcelona, Spain; ICU Department, Hospital Universitari Parc del Mar, Barcelona, Spain; General Direction of Public Health, Quality and Innovation, Ministry of Health, Social Services and Equality, Madrid, Spain.

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http://dx.doi.org/10.1097/CCM.0000000000000080DOI Listing
February 2014

Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: the Spanish experience.

Crit Care Med 2013 Oct;41(10):2364-72

1Intensive Care Unit, Hospital Universitari Arnau de Vilanova, Lleida, Universitat Autònoma de Barcelona, Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), Barcelona, Spain. 2Intensive Care Unit, Parc de Salut Mar, Universitat Autònoma de Barcelona, SEMICYUC, Barcelona, Spain. 3Intensive Care Unit, Hospital Universitari Vall d´Hebron, Barcelona, Spain. 4Patient Safety Programme, World Health Organization, Geneva, Switzerland. 5Statistics and Methodology Support Unit (USEM), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain. 6Quality Agency of the National Health System, Spanish Ministry of Health, Social Policy and Equality, Madrid, Spain. 7Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, Johns Hopkins University School of Medicine, Bloomberg School of Public Health, and School of Nursing, Baltimore, MA.

Objective: Prevention of catheter-related bloodstream infection is a basic objective to optimize patient safety in the ICU. Building on the early success of a patient safety unit-based comprehensive intervention (the Keystone ICU project in Michigan), the Bacteremia Zero project aimed to assess its effectiveness after contextual adaptation at large-scale implementation in Spanish ICUs.

Design: Prospective time series.

Setting: A total of 192 ICUs throughout Spain.

Patients: All patients admitted to the participating ICUs during the study period (baseline April 1 to June 30, 2008; intervention period from January 1, 2009, to June 30, 2010).

Intervention: Engagement, education, execution, and evaluation were key program features. Main components of the intervention included a bundle of evidence-based clinical practices during insertion and maintenance of catheters and a unit-based safety program (including patient safety training and identification and analysis of errors through patient safety rounds) to improve the safety culture.

Measurements And Main Results: The number of catheter-related bloodstream infections was expressed as median and interquartile range. Poisson distribution was used to calculate incidence rates and risk estimates. The participating ICUs accounted for 68% of all ICUs in Spain. Catheter-related bloodstream infection was reduced after 16-18 months of participation (median 3.07 vs 1.12 episodes per 1,000 catheter-days, p<0.001). The adjusted incidence rate of bacteremia showed a 50% risk reduction (95% CI, 0.39-0.63) at the end of the follow-up period compared with baseline. The reduction was independent of hospital size and type.

Conclusions: Results of the Bacteremia Zero project confirmed that the intervention significantly reduced catheter-related bloodstream infection after large-scale implementation in Spanish ICUs. This study suggests that the intervention can also be effective in different socioeconomic contexts even with decentralized health systems.
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http://dx.doi.org/10.1097/CCM.0b013e3182923622DOI Listing
October 2013

Morbidity and mortality associated with primary and catheter-related bloodstream infections in critically ill patients.

Rev Esp Quimioter 2013 Mar;26(1):21-9

Intensive Care Medicine Department. Galdakao-Usansolo Hospital, Vizcaya, Spain.

Purpose: To analyze the impact of primary and catheterrelated bloodstream infections (PBSI/CRBSI) on morbidity and mortality.

Methods: A matched case-control study (1:4) was carried out on a Spanish epidemiological database of critically ill patients (ENVIN-HELICS). To determine the risk of death in patients with PBSI/CRBSI a matched Cox proportional hazard regression analysis was performed.

Results: Out of the 74,585 registered patients, those with at least one episode of monomicrobial PBSI/CRBSI were selected and paired with patients without PBSI/CRBSI for demographic and diagnostic criteria and seriousness of their condition on admission to the Intensive Care Unit (ICU). for mortality analysis, 1,879 patients with PBSI/CRBSI were paired with 7,516 controls. The crude death rate in the ICU was 28.1% among the cases and 18.7% among the controls. Attributable mortality 9.4% (HR:1.20; 95% confidence interval: 1.07-1.34; p<0.001). Risk of death varied according to the source of infection, aetiology, moment of onset of bloodstream infection and severity on admission to the ICU. The median stay in the ICU of patients who survived PBSI/CRBSI was 13 days longer than the controls, also varying according to aetiology, moment of onset of bloodstream infection and severity on admission.

Conclusions: Acquisition of PBSI/CRBSI in critically ill patients significantly increases mortality and length of ICU stay, which justifies prevention efforts.
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March 2013

Prevention of ventilator-associated pneumonia in intensive care units: an international online survey.

Antimicrob Resist Infect Control 2013 Mar 26;2(1). Epub 2013 Mar 26.

Healthcare associated infections unit, Scientific Institute of Public Health, Rue Juliette Wytsmanstraat 14, Brussels, 1050, Belgium.

Background: On average 7% of patients admitted to intensive-care units (ICUs) suffer from a potentially preventable ventilator-associated pneumonia (VAP). Our objective was to survey attitudes and practices of ICUs doctors in the field of VAP prevention.

Methods: A questionnaire was made available online in 6 languages from April, 1st to September 1st, 2012 and disseminated through international and national ICU societies. We investigated reported practices as regards (1) established clinical guidelines for VAP prevention, and (2) measurement of process and outcomes, under the assumption "if you cannot measure it, you cannot improve it"; as well as attitudes towards the implementation of a measurement system. Weighted estimations for Europe were computed based on countries for which at least 10 completed replies were available, using total country population as a weight. Data from other countries were pooled together. Detailed country-specific results are presented in an online additional file.

Results: A total of 1730 replies were received from 77 countries; 1281 from 16 countries were used to compute weighted European estimates, as follows: care for intubated patients, combined with a measure of compliance to this guideline at least once a year, was reported by 57% of the respondents (95% CI: 54-60) for hand hygiene, 28% (95% CI: 24-33) for systematic daily interruption of sedation and weaning protocol, and 27% (95%: 23-30) for oral care with chlorhexidine. Only 20% (95% CI: 17-22) were able to provide an estimation of outcome data (VAP rate) in their ICU, still 93% (95% CI: 91-94) agreed that "Monitoring of VAP-related measures stimulates quality improvement". Results for 449 respondents from 61 countries not included in the European estimates are broadly comparable.

Conclusions: This study shows a low compliance with VAP prevention practices, as reported by ICU doctors in Europe and elsewhere, and identifies priorities for improvement.
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http://dx.doi.org/10.1186/2047-2994-2-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3623895PMC
March 2013

Evolution over a 15-year period of clinical characteristics and outcomes of critically ill patients with community-acquired bacteremia.

Crit Care Med 2013 Jan;41(1):76-83

Critical Care Center, Parc Taulí Hospital-Sabadell, UAB, CIBER enfermedades respiratorias, Sabadell, Spain.

Objective: In recent years, outcomes for critically ill patients with severe sepsis have improved; however, no data have been reported about the outcome of patients admitted for community-acquired bacteremia. We aimed to analyze the changes in the prevalence, characteristics, and outcome of critically ill patients with community-acquired bacteremia over the past 15 yrs.

Design: A secondary analysis of prospective cohort studies in critically ill patients in three annual periods (1993, 1998, and 2007).

Setting: Forty-seven ICUs at secondary and tertiary care hospitals.

Patients: All adults admitted to the participating ICUs with at least one true-positive blood culture finding within the first 48 hrs of admission.

Interventions: None.

Measurements And Main Results: A total of 829 patients was diagnosed with community-acquired bacteremia during the study periods (148, 196, and 485 in the three periods). The prevalence density rate of community-acquired bacteremia increased from nine per 1000 ICU admissions in 1993 to 24.4 episodes per 1,000 ICU admissions in 2007 (p < 0.001). The prevalence of septic shock also increased from 4.6 episodes/1,000 admissions in 1993 to 14.6 episodes/1,000 admissions in 2007 (p < 0.001). Patients with community-acquired bacteremia were significantly older and had more comorbidities. No significant differences were observed in the presence of Gram-positive and Gram-negative micro-organisms among the three study periods. Mortality related to community-acquired bacteremia decreased over the three study periods: 42%, 32.2%, and 22.9% in 1993, 1998, and 2007, respectively (p < 0.01). The occurrence of septic shock and the number of comorbidities were independently associated with worse outcome. Appropriate antibiotic therapy and development of community-acquired bacteremia in 1998 and 2007 were independently associated with better survival.

Conclusions: The prevalence of community-acquired bacteremia in ICU patients has increased. Despite a higher percentage of more severe and older patients, the mortality associated with community-acquired bacteremia decreased. Improved management of severe sepsis might explain the improvements in outcomes.
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http://dx.doi.org/10.1097/CCM.0b013e3182676698DOI Listing
January 2013

Antibiotic consumption at 46 VINCat hospitals from 2007 to 2009, stratified by hospital size and clinical services.

Enferm Infecc Microbiol Clin 2012 Jun;30 Suppl 3:43-51

Pharmacy Service, Hospital del Mar, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.

The aim of the study was to assess the evolution of antibiotic consumption in acute care hospitals in Catalonia (population 7.5 million), according to hospital size and department, during the period 2007-2009. The methodology used for monitoring antibiotic consumption was the ATC/DDD system, and the unit of measurement was DDD/100 occupied bed-days (DDD/100 OBD). Hospitals were stratified according to size: I) large university hospitals (with more than 500 beds); II) medium-sized hospitals (between 200 and 500 beds); and III) small hospitals (fewer than 200 beds). The consumption was also analyzed and stratified according to department: medical, surgical and intensive care unit (ICU). Specific training in data management on antibiotic consumption was given to all participant hospitals before the implementation of the program. The mean antibiotic (J01) consumption, calculated in DDD/100 OBD, increased although without statistical significance (p=0.640): 74.68 (2007), 75.13 (2008) and 78.04 (2009). The values of the medians expressed in DDD/100 OBD in group I were 83.27 (in 2007), 82.16 (2008) and 86.93 (2009), in group II 72.60 (2007), 70.78 (2008) and 75.17 (2009) and in group III 65.66 (2007), 69.32 (2008) and 72.39 (2009). Antibiotic consumption was higher in large hospitals than in medium-sized or small hospitals. Catalan hospitals recorded an increase of 4.49% from 2007 to 2009, especially due to the rising use of carbapenems, cephalosporins, monobactams and the other antibiotic groups.
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http://dx.doi.org/10.1016/S0213-005X(12)70096-4DOI Listing
June 2012

Device-associated infection rates in Adult Intensive Care Units in Catalonia: VINCat Program findings.

Enferm Infecc Microbiol Clin 2012 Jun;30 Suppl 3:33-8

Critical Care Unit, Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Barcelona, Spain. CIBER Enfermedades Respiratorias.

Hospital-acquired infections are a leading cause of morbidity and mortality, especially in the intensive care unit (ICU). Surveillance of device-associated infections plays a major role in infection control programs. In 2006, the Surveillance Program of Nosocomial Infections in Catalonia (VINCat Program) was started, with the major aim of reducing infection rates through a process of active monitoring. The study period comprised calendar years 2008 (with 21 ICUs participating), 2009 (with 21 ICUs participating), and 2010 (with 28 ICUs participating). Each participating hospital was required to have an infection control team made up of at least one physician, an infection surveillance nurse, and a microbiology laboratory. Hospitals were classified into three groups according to their size. Central venous catheter-associated bloodstream infection (CVC-BSI) and ventilator-associated pneumonia (VAP) were chosen as the device-associated infections to analyze. Incidence rates of device-associated infections were calculated by dividing the total number of device-associated infection (VAP or CVC-BSI) days by the total number of days use for the relevant device. Mechanical ventilation use ranged from 0.10 to 0.85 days (overall, 0.35), and central venous catheter use ranged from 0.18 to 0.98 days (overall, 0.65). Incidence rates of VAP ranged from 7.2 ± 3.7 to 10.7 ± 9.6 episodes of VAP/1000 ventilator days. Incidence rates of CVC-BSl ranged from 1.9 ± 1.6 to 2.7 ± 2.0 episodes of CVC-associated bloodstream infection/1000 central venous catheter days. The implementation of the VINCat Program allowed monitoring of nosocomial device-associated infections in ICUs in Catalonia and enabled corrective measures in ICUs with increased incidences of device-associated infections.
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http://dx.doi.org/10.1016/S0213-005X(12)70094-0DOI Listing
June 2012

Concordance between European and US case definitions of healthcare-associated infections.

Antimicrob Resist Infect Control 2012 Aug 2;1(1):28. Epub 2012 Aug 2.

Institute for Hygiene and Environmental Medicine, Charité - University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 27, D-12203, Berlin, Germany.

Unlabelled:

Background: Surveillance of healthcare-associated infections (HAI) is a valuable measure to decrease infection rates. Across Europe, inter-country comparisons of HAI rates seem limited because some countries use US definitions from the US Centers for Disease Control and Prevention (CDC/NHSN) while other countries use European definitions from the Hospitals in Europe Link for Infection Control through Surveillance (HELICS/IPSE) project. In this study, we analyzed the concordance between US and European definitions of HAI.

Methods: An international working group of experts from seven European countries was set up to identify differences between US and European definitions and then conduct surveillance using both sets of definitions during a three-month period (March 1st -May 31st, 2010). Concordance between case definitions was estimated with Cohen's kappa statistic (κ).

Results: Differences in HAI definitions were found for bloodstream infection (BSI), pneumonia (PN), urinary tract infection (UTI) and the two key terms "intensive care unit (ICU)-acquired infection" and "mechanical ventilation". Concordance was analyzed for these definitions and key terms with the exception of UTI. Surveillance was performed in 47 ICUs and 6,506 patients were assessed. One hundred and eighty PN and 123 BSI cases were identified. When all PN cases were considered, concordance for PN was κ = 0.99 [CI 95%: 0.98-1.00]. When PN cases were divided into subgroups, concordance was κ = 0.90 (CI 95%: 0.86-0.94) for clinically defined PN and κ = 0.72 (CI 95%: 0.63-0.82) for microbiologically defined PN. Concordance for BSI was κ = 0.73 [CI 95%: 0.66-0.80]. However, BSI cases secondary to another infection site (42% of all BSI cases) are excluded when using US definitions and concordance for BSI was κ = 1.00 when only primary BSI cases, i.e. Europe-defined BSI with "catheter" or "unknown" origin and US-defined laboratory-confirmed BSI (LCBI), were considered.

Conclusions: Our study showed an excellent concordance between US and European definitions of PN and primary BSI. PN and primary BSI rates of countries using either US or European definitions can be compared if the points highlighted in this study are taken into account.
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http://dx.doi.org/10.1186/2047-2994-1-28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527198PMC
August 2012

Appropriateness is critical.

Crit Care Clin 2011 Jan;27(1):35-51

Critical Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain.

Inappropriate empirical antibiotic therapy for severe infections in the intensive care unit is a modifiable prognostic factor that has a great effect on patient outcome and health care resources. Inappropriate treatment is usually associated with microorganisms resistant to the common antibiotics, which must be empirically targeted when risk factors are present. Previous antibiotic exposure, prolonged length of hospital stay, admission category, local susceptibilities, colonization pressure, and the presence of invasive devices increase the likelihood of infection by resistant pathogens. Consideration of issues beyond in vitro susceptibility, such as antibiotic physicochemistry, tissue penetration, and pharmacokinetic/pharmacodynamic-driven dosing, is mandatory for the optimization of antibiotic use.
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http://dx.doi.org/10.1016/j.ccc.2010.09.007DOI Listing
January 2011

Clinical outcomes of health-care-associated infections and antimicrobial resistance in patients admitted to European intensive-care units: a cohort study.

Lancet Infect Dis 2011 Jan 2;11(1):30-8. Epub 2010 Dec 2.

Public Health and Surveillance Department, Scientific Institute for Public Health, Brussels, Belgium.

Background: Patients admitted to intensive-care units are at high risk of health-care-associated infections, and many are caused by antimicrobial-resistant pathogens. We aimed to assess excess mortality and length of stay in intensive-care units from bloodstream infections and pneumonia.

Methods: We analysed data collected prospectively from intensive-care units that reported according to the European standard protocol for surveillance of health-care-associated infections. We focused on the most frequent causative microorganisms. Resistance was defined as resistance to ceftazidime (Acinetobacter baumannii or Pseudomonas aeruginosa), third-generation cephalosporins (Escherichia coli), and oxacillin (Staphylococcus aureus). We defined 20 different exposures according to infection site, microorganism, and resistance status. For every exposure, we compared outcomes between patients exposed and unexposed by use of time-dependent regression modelling. We adjusted results for patients' characteristics and time-dependency of the exposure.

Findings: We obtained data for 119 699 patients who were admitted for more than 2 days to 537 intensive-care units in ten countries between Jan 1, 2005, and Dec 31, 2008. Excess risk of death (hazard ratio) for pneumonia in the fully adjusted model ranged from 1·7 (95% CI 1·4-1·9) for drug-sensitive S aureus to 3·5 (2·9-4·2) for drug-resistant P aeruginosa. For bloodstream infections, the excess risk ranged from 2·1 (1·6-2·6) for drug-sensitive S aureus to 4·0 (2·7-5·8) for drug-resistant P aeruginosa. Risk of death associated with antimicrobial resistance (ie, additional risk of death to that of the infection) was 1·2 (1·1-1·4) for pneumonia and 1·2 (0·9-1·5) for bloodstream infections for a combination of all four microorganisms, and was highest for S aureus (pneumonia 1·3 [1·0-1·6], bloodstream infections 1·6 [1·1-2·3]). Antimicrobial resistance did not significantly increase length of stay; the hazard ratio for discharge, dead or alive, for sensitive microorganisms compared with resistant microorganisms (all four combined) was 1·05 (0·97-1·13) for pneumonia and 1·02 (0·98-1·17) for bloodstream infections. P aeruginosa had the highest burden of health-care-acquired infections because of its high prevalence and pathogenicity of both its drug-sensitive and drug-resistant strains.

Interpretation: Health-care-associated bloodstream infections and pneumonia greatly increase mortality and pneumonia increase length of stay in intensive-care units; the additional effect of the most common antimicrobial resistance patterns is comparatively low.

Funding: European Commission (DG Sanco).
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http://dx.doi.org/10.1016/S1473-3099(10)70258-9DOI Listing
January 2011

Health-care-associated bloodstream infections at admission to the ICU.

Chest 2011 Apr 24;139(4):810-815. Epub 2010 Nov 24.

Hospital Valme, Sevilla, Spain.

Background: Infections occurring among outpatients having recent contact with the health-care system have been recently classified as health-care-associated infections to distinguish them from hospital- and community-acquired infections. Patients with bloodstream infections (BSIs) were studied to assess health-care-associated infections at admission in the ICU.

Methods: This work was a multicenter, prospective, observational study of all adult patients with BSI at ICU admission at 27 Spanish hospitals and one Argentine hospital. Cases of BSI were classified as community-acquired BSI (CAB), health-care-associated BSI (HCAB), or hospital-acquired BSI (HAB), and their characteristics were compared.

Results: Of 726 BSIs, 343 (47.2%) were CABs, 252 (34.7%) were HABs, and 131 (18.0%) were HCABs. Potentially antibiotic-resistant pathogens were more frequently isolated in HABs (34.8%) and HCABs (27.6%) than in CABs (10.3%) (P < .001). Logistic regression analysis revealed that HABs (OR, 4.6; 95% CI, 2.9-7.3), HCABs (OR, 3.1; 95% CI, 1.8-5.4), and BSIs of unknown origin (OR, 1.7; 95% CI, 1.0-2.8) were independently associated with the isolation of potentially antibiotic-resistant pathogens. The incidence of inappropriate treatment was significantly higher in HABs (OR, 3.4; 95% CI, 2.1-5.3) and in HCABs (OR, 1.8; 95% CI, 1.0-3.2) than in CABs.

Conclusions: One in five BSIs diagnosed at ICU admission is health-care-associated. The incidence of potentially drug-resistant pathogens in HCABs is more similar to that of HABs, and they should be treated as such until culture data are available.
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http://dx.doi.org/10.1378/chest.10-1715DOI Listing
April 2011

[To Ithaca without Odysseus].

Enferm Infecc Microbiol Clin 2009 Dec 6;27(10):559-60. Epub 2009 Nov 6.

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http://dx.doi.org/10.1016/j.eimc.2009.07.007DOI Listing
December 2009

[Evaluation of the status of patients with severe infection, criteria for intensive care unit admittance. Spanish Society for Infectious Diseases and Clinical Microbiology. Spanish Society of Intensive and Critical Medicine and Coronary Units].

Enferm Infecc Microbiol Clin 2009 Jun 1;27(6):342-52. Epub 2009 May 1.

Medicina Intensiva, Hospital de Galdakao, Vizcaya, España.

Recent studies have shown that early attention in patients with serious infections is associated with a better outcome. Assistance in intensive care units (ICU) can effectively provide this attention; hence patients should be admitted to the ICU as soon as possible, before clinical deterioration becomes irreversible. The objective of this article is to compile the recommendations for evaluating disease severity in patients with infections and describe the criteria for ICU admission, updating the criteria published 10 years ago. A literature review was carried out, compiling the opinions of experts from the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC, Spanish Society for Infectious Diseases and Clinical Microbiology) and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC, Spanish Society for Intensive Medicine, Critical Care and Coronary Units) as well as the working groups for infections in critically ill patients (GEIPC-SEIMC and GTEI-SEMICYUC). We describe the specific recommendations for ICU admission related to the most common infections affecting patients, who will potentially benefit from critical care. Assessment of the severity of the patient's condition to enable early intensive care is stressed.
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http://dx.doi.org/10.1016/j.eimc.2008.05.008DOI Listing
June 2009

[Consensus document for the treatment of bacteremia and endocarditis caused by methicillin-resistent Staphylococcus aureus. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica].

Enferm Infecc Microbiol Clin 2009 Feb 11;27(2):105-15. Epub 2009 Feb 11.

Servicio de Enfermedades Infecciosas, IDIBELL, Hospital Universitario de Bellvitge, Barcelona, España.

Bacteremia and endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) are prevalent and clinically important. The rise in MRSA bacteremia and endocarditis is related with the increasing use of venous catheters and other vascular procedures. Glycopeptides have been the reference drugs for treating these infections. Unfortunately their activity is not completely satisfactory, particularly against MRSA strains with MICs > 1 microg/mL. The development of new antibiotics, such as linezolid and daptomycin, and the promise of future compounds (dalvabancin, ceftobiprole and telavancin) may change the expectatives in this field.The principal aim of this consensus document was to formulate several recommendations to improve the outcome of MRSA bacteremia and endocarditis, based on the latest reported scientific evidence. This document specifically analyzes the approach for three clinical situations: venous catheter-related bacteremia, persistent bacteremia, and infective endocarditis due to MRSA.
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http://dx.doi.org/10.1016/j.eimc.2008.09.003DOI Listing
February 2009

Risk factors for candidaemia in critically ill patients: a prospective surveillance study.

Mycoses 2007 Jul;50(4):302-10

Department of Intensive Care Medicine, Hospital Son Dureta and Clínica Rotger, Palma de Mallorca, Spain.

Candidaemia is frequently a life-threatening complication in patients admitted to the intensive care unit (ICU). To assess the risk factors for candidaemia in critically ill patients with prolonged ICU stay, a total of 1765 adult patients admitted for at least 7 days to 73 medical-surgical ICUs of 70 tertiary care hospitals in Spain participated in a prospective cohort study. Candidaemia was defined as recovery of Candida spp. from blood culture. Sixty-eight episodes of candidaemia occurred in 63 patients, representing 35.7 episodes per 1000 ICU patients admitted, with an incidence rate of 1.5 episodes per 1000 days of ICU stay. Causative fungi were C. albicans in 57.1% of cases and non-albicans Candida spp. in 42.9%. In the multivariate analysis, independent factors significantly associated with candidaemia were Candida colonisation (OR = 4.12, 95% CI: 1.82-9.33), total parenteral nutrition (OR = 3.89, 95% CI: 1.73-8.78), elective surgery (OR = 2.75, 95% CI: 1.17-6.45) and haemofiltration procedures (OR = 1.96, 95% CI: 1.06-3.62). In the ICU setting in Spain and in patients who have stayed in units for >7 days, more than half of cases of candidaemia were caused by C. albicans. Risk factors for candidaemia identified included Candida colonisation, elective surgery, total parenteral nutrition and haemodialysis.
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http://dx.doi.org/10.1111/j.1439-0507.2007.01366.xDOI Listing
July 2007

Intensive care medicine in Europe.

Crit Care Clin 2006 Jul;22(3):425-32, viii

Medical Intensive Care Unit, AP-HP, Hospital St. Antoine, Faculté de Médecine, Saint-Antoine, Paris F-75012, France, and Services de Cuidados Intensivos Hospital Universitario Vall d'Hebron, Barcelona, Spain.

Health care systems stem from specific political, historical, cultural,and socioeconomic traditions. As a result, the organizational arrangements for health care differ considerably between Member States of the European Union. Health care in the European Union is at a crossroads between challenges and opportunities. The Member States are facing common challenges in delivering equal, efficient, and high-quality health services at affordable cost in times when the amount of care to be delivered is starting to exceed the resource base.
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http://dx.doi.org/10.1016/j.ccc.2006.03.007DOI Listing
July 2006

[Treatment for Legionnaires' disease. Macrolides or quinolones?].

Enferm Infecc Microbiol Clin 2006 Jun-Jul;24(6):360-4

Servicios de Enfermedades Infecciosas, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, España.

Background: Macrolides and fluoroquinolones are the recommended treatment for Legionnaires' disease. The aim of our study was to analyze the clinical efficacy of clarithromycin, azithromycin and levofloxacin in patients with Legionnaires' disease.

Methods: Prospective, observational study involving all adult patients with Legionella pneumophila pneumonia attended at Hospital Universitario Vall d'Hebron (Barcelona, Spain) from January 2001 to December 2004. Duration of fever, length of hospital stay and mortality were compared among 52 patients treated with clarithromycin, 43 with azithromycin and 18 with levofloxacin.

Results: The proportion of patients with risk factors for Legionnaires' disease, the initial severity of the pneumonia and the number of patients who required intensive care unit admission were similar in patients treated with clarithromycin, azithromycin and levofloxacin. In-hospital mortality was 5.3%. There were no significant differences in fever duration, length of hospital stay or mortality among the 3 groups of patients.

Conclusion: In our experience, clarithromycin, azithromycin and levofloxacin were all efficacious for the treatment of Legionnaires' disease.
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http://dx.doi.org/10.1157/13089688DOI Listing
November 2006

[Staphylococcus aureus nosocomial infections in critically ill patients admitted in intensive care units].

Med Clin (Barc) 2006 May;126(17):641-6

Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, España.

Background And Objective: To investigate the frequency of nosocomial infections caused by Staphylococcus aureus in critically ill patients admitted to Spanish intensive care units (ICUs) and to describe the characteristics and outcome of patients in whom this pathogen was isolated.

Patients And Method: Prospective, observational, and multicenter study. All patients admitted during one or 2 months to the participating ICUs in the National Nosocomial Infection Surveillance Study (ENVIN) between 1997 and 2003 were included. Patients were classified as infected by S. aureus, infected by other microorganisms, and without nosocomial infection.

Results: A total of 34,914 patients were controlled of whom 3,450 (9.9%) had acquired a nosocomial infection during his/her ICU stay (16.0 infections per 100 patients). In 682 (19.8%) patients, a total of 775 infectious episodes in which one of the microorganisms isolated was S. aureus were documented (cumulative incidence 2.2 episodes of S. aureus infection per 100 patients). There was a predominance of S. aureus infection in patients with pneumonia associated with mechanical ventilation (21.4%) and in patients with catheter-related bacteremia (13%). Independent variables associated with S. aureus infection were male sex (odds ratio [OR] = 1.25; 95% confidence interval [CI], 1.03-1.52) and underlying trauma pathology (OR = 1.72, 95%; 95%CI, 1.26-2.35), whereas an older age has been a protective factor (OR = 0.90; 95%CI, 0.84-0.96). Mortality in patients with S. aureus infection was significantly higher than in infections caused by other microorganisms, and in both cases higher than in patients without infection (34.5%, 30.3%, and 10.7%, respectively). In 208 (30.5%) patients, infections due to methicillin-resistant S. aureus were diagnosed, which in turn had increased significantly over the years (p = 0.001). Mortality in patients with methicillin-resistant S. aureus infection was 35.1% compared with 34.2% in patients with methicillin sensitive S. aureus infections (p = NS).

Conclusions: S. aureus was isolated in 19.8% of patients with ICU-acquired infection, particularly in relation to pneumonia in mechanically ventilated patients. Mortality in patients with S. aureus infection was higher than that in patients with infections due to other microorganisms and patients without infection. In contrast, differences in the outcome of patients with infections caused by methicillin-sensitive or methicillin-resistant S. aureus were not found.
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http://dx.doi.org/10.1157/13087841DOI Listing
May 2006

[Infections caused by Acinetobacter spp. in critically ill ICU patients].

Enferm Infecc Microbiol Clin 2005 Nov;23(9):533-9

Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain.

Introduction: To determine the frequency of infections caused by Acinetobacter spp. in critically ill patients admitted to Spanish intensive care units (ICUs) and to assess the clinical features and outcome.

Patients And Method: Prospective, observational, multicenter study. Patients admitted for one or two months to ICUs participating in the Spanish Nosocomial Surveillance Study (ENVIN project) between 1997 and 2003 were included. Patients were classified into the following groups: infected by Acinetobacter spp., infected by other pathogens, and uninfected.

Results: In 343 (9.9%) patients from among 3,450 with nosocomial infection, Acinetobacter spp. was one of the pathogens identified in 406 episodes (cumulative incidence, 1.2 episodes per 100 patients). A. baumannii was the predominant species in 357 cases (87.9%). Variables significantly associated with selection of Acinetobacter spp. were medical (OR: 2.47; 95% CI: 1.24-4.91) or traumatic underlying disease (OR: 4.40; 95% CI: 2.20-8.80) and ICU stay (OR: 1.03; 95% CI: 1.02-1.04). The overall mortality rate in ICU patients with infection (31.1%) was similar to that of patients with Acinetobacter spp. infections (31.5%), although in both cases it was significantly higher than mortality in uninfected patients (10.7%). ICU mortality rates in patients with imipenem-resistant and imipenem-sensitive Acinetobacter spp. infections were not significantly different (33.3% vs. 30.0%; p = 0.7283).

Conclusions: Acinetobacter spp. were present in 9.9% of patients with ICU-acquired infection. There were no significant differences in ICU mortality rates between patients with Acinetobacter spp. infection and patients with infections caused by other microorganisms.
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http://dx.doi.org/10.1157/13080263DOI Listing
November 2005