Geographical differences for pneumococcal disease.
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Child, Preschool↗
Biomedical subjects
R Pallares
Publications and source records attributed to R Pallares.
Pneumococcal peritonitis in adult patients: report of 64 cases with special reference to emergence of antibiotic resistance.
BACKGROUND: Few data are available regarding pneumococcal peritonitis. We studied the clinical characteristics of intra-abdominal infections caused by Streptococcus pneumoniae and its prognosis in relation to antibiotic resistance. METHODS: We reviewed all cases of culture-proved pneumococcal peritonitis. Patients with liver cirrhosis and primary pneumococcal peritonitis were compared with patients with Escherichia coli peritonitis. RESULTS: Between January 1, 1979, and December 31, 1998, we identified 45 cases of primary pneumococcal peritonitis in patients with cirrhosis and 19 cases of secondary (or tertiary) pneumococcal peritonitis. Patients with cirrhosis and primary pneumococcal peritonitis vs those with primary E coli peritonitis had more frequent community-acquired infection, 73% vs 47%; pneumonia, 36% vs 2%; and bacteremia, 76% vs 33%; and higher attributable mortality (early mortality), 27% vs 9% (P<.05 for all). Secondary (or tertiary) pneumococcal peritonitis was associated with upper or lower gastrointestinal tract diseases; in most cases, the infection appeared after surgery. A hematogenous spread of S pneumoniae from a respiratory tract infection might be the most important origin of peritonitis; also, S pneumoniae might directly reach the gastrointestinal tract favored by endoscopic procedures or hypochlorhydria. There was an increased prevalence of penicillin and cephalosporin resistance up to 30.7% and 17.0%, respectively, although it was not associated with increased mortality rates. CONCLUSIONS: Primary pneumococcal peritonitis in patients with cirrhosis more often spread hematogenously from the respiratory tract and was associated with early mortality. In secondary (and tertiary) pneumococcal peritonitis, a transient gastrointestinal tract colonization and inoculation during surgery might be the most important mechanisms. Current levels of resistance were not associated with increased mortality rates.
Adult↗
Usefulness of betalactam therapy for community-acquired pneumonia in the era of drug-resistant Streptococcus pneumoniae: a randomized study of amoxicillin-clavulanate and ceftriaxone.
Empirical antibiotic therapy of community-acquired pneumonia (CAP) has been complicated by the worldwide emergence of penicillin resistance among Streptococcus pneumoniae. The impact of this resistance on the outcome of patients hospitalized for CAP, empirically treated with betalactams, has not been evaluated in a randomized study. We conducted a prospective, randomized trial to assess the efficacy of amoxicillin-clavulanate (2 g/200 mg/8 hr) and ceftriaxone (1 g/24 hr) in a cohort of patients hospitalized for moderate-to-severe CAP. Three-hundred seventy-eight patients were randomized to receive amoxicillin-clavulanate (184 patients) or ceftriaxone (194 patients). Efficacy was assessed on Day 2, after completion of therapy and at long term follow-up. There were no significant differences in outcomes between treatment groups, both in intention-to-treat and per-protocol analysis. Overall mortality was 10.3% for amoxicillin-clavulanate and 8.8% for ceftriaxone (NS). There were 116 evaluable patients with proven pneumococcal pneumonia. Rates of high-level penicillin resistance (MIC of penicillin > or = 2 microg/mL) were similar in the two groups (8.2 and 10.2%). Clinical efficacy at the end of therapy was 90.6% for amoxicillin-clavulanate and 88.9% for ceftriaxone (95% C.I. of the difference: -9.3 to +12.7%). No differences in outcomes were attributable to differences in penicillin susceptibility of pneumococcal strains. Sequential i.v./oral amoxicillin-clavulanate and parenteral ceftriaxone were equally safe and effective for the empirical treatment of acute bacterial pneumonia, including penicillin and cephalosporin-resistant pneumococcal pneumonia. The use of appropriate betalactams in patients with penumococcal pneumonia and in the overall CAP population, is reliable at the current level of resistance.
Aged↗
Impact of a resident strike on emergency department quality indicators at an urban teaching hospital.
OBJECTIVE: To evaluate the indicators of activity and quality within the emergency department (ED) during a resident physicians' strike. METHODS: This was an observational study comparing a strike period (SP) and a non-strike period (NSP) in the ED of a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, with an annual census of 100,000 emergency visits. During a period of nine nonconsecutive days, the resident physicians were on strike. Emergency visits were handled by staff members. Data were compared between all patients treated in the ED during the SP and those treated during the NSP, matched by the weekday. The authors compared lengths of stay (LOSs), rates of use of laboratory tests and radiology procedures, numbers of patient walkouts, patient/physician ratios, emergency hospital admission rates, home discharge rates, unscheduled return rates, and mortality rates. RESULTS: The two groups (SP 2,610 patients and NSP 3,634 patients) were comparable in terms of average daily attendance rate (SP: 290 +/- 12 vs NSP: 302 +/- 21; p = 0.13), elective hospital admission rate, and severity of illness. Statistically significant differences were found in terms of mean total patients' LOS (SP: 206.75 +/- 12.27 vs NSP: 235.10 +/- 27.08 minutes; p < 0.001), number of laboratory tests per patient (SP: 0.30 +/- 0.05 vs NSP: 0.38 +/- 0.04; p < 0.001), and radiographs per patient (SP: 0.78 +/- 0.06 vs NSP: 0.88 +/- 0.09; p = 0.021). CONCLUSIONS: This study demonstrated that replacing residents with staff physicians resulted in fewer laboratory tests ordered, fewer radiographs ordered, and shorter lengths of stays in the ED.
Adult↗
Epidemiologic relation between HIV and invasive pneumococcal disease in San Francisco County, California.
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AIDS-Related Opportunistic Infections↗
Fluoroquinolone resistance in Streptococcus pneumoniae.
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Anti-Infective Agents↗
Treatment of pneumococcal pneumonia.
The emergence of Streptococcus pneumoniae strains with resistance to penicillin, macrolide, and other drugs has made the treatment of pneumococcal infections more complicated. Although resistance to penicillin has had a profound impact on the outcome of meningitis, it has had little impact on the mortality from pneumococcal pneumonia because the serum and pulmonary levels achieved with penicillin (or related drugs) are several times higher than the minimal inhibitory concentration of the strains. Thus, based on current levels of resistance to penicillin and cephalosporin, most patients with mild/moderate pneumococcal pneumonia may respond to oral amoxicillin, and most with severe pneumonia may be successfully treated with intravenous ceftriaxone, cefotaxime, or amoxicillin-clavulanic acid. It is of concern that patients infected with erythromycin-resistant pneumococci may not respond to therapy with a macrolide. In our opinion, except for well-selected patients, imipenem and vancomycin should not be widely used for the treatment of pneumococcal pneumonia. Some new drugs such as the new quinolones may play an important role in the management of pneumonia in the near future.
Anti-Bacterial Agents↗
Clinical and epidemiological findings in mechanically-ventilated patients with methicillin-resistant Staphylococcus aureus pneumonia.
Over the 5-year period from 1990 to 1994, a prospective cohort study was conducted to define the clinical and epidemiological characteristics of ventilator-associated methicillin-resistant Staphylococcus aureus (MRSA) pneumonia acquired during a large-scale outbreak of MRSA infection. Of 2411 mechanically ventilated patients, 347 (14.4%) acquired MRSA, 220 (63.4%) had MRSA positive respiratory tract samples and 41 (18.6%) developed ventilator-associated MRSA pneumonia. The overall attack rate for ventilator-associated MRSA pneumonia was 1.56 episodes/1000 ventilator days, but annual attack rates varied according to the trend of the outbreak (range 4.9-0.2). In comparison with methicillin-sensitive Staphylococcus aureus (MSSA), which was implicated in 98 episodes of ventilator-associated pneumonia, MRSA caused exclusively late-onset ventilator-associated pneumonia, while MSSA caused both early-onset [55 of 98 (56.1%) episodes] and late-onset [43 of 98 (43.8%) episodes] ventilator-associated pneumonia. Logistic regression analysis of all patients with Staphylococcus aureus pneumonia revealed intubation for more than 3 days (odds ratio (OR),1.11; confidence interval (CI):1.03-1.18) and prior bronchoscopy (OR,5.8; CI,1.85-18.19) to be independent variables associated with MRSA pneumonia. The results indicate that MRSA ventilator-associated pneumonia is a frequent complication in intensive care patients, manifesting itself as late-onset pneumonia in patients who have been intubated for prolonged periods and/or have often undergoing previous bronchoscopy.
Adult↗
Efficacy and safety of an early discharge protocol in low-risk patients with upper gastrointestinal bleeding.
PURPOSE: The outcome of patients with upper gastrointestinal hemorrhage is greatly influenced by recurrence of bleeding, but it may be possible to identify patients who have a low risk for rebleeding, and can be discharged after a short hospitalization. To examine the effect of an early discharge protocol (length of hospital stay < or =3 days), we conducted a 2-year prospective study in patients with upper gastrointestinal bleeding at low risk for rebleeding, as selected by clinical and endoscopic criteria. METHODS: During the first year of the study, patients were managed according to the standard criteria by any of six surgical teams (control period). During the second year, patients were managed by only one surgical team under the early discharge protocol guidelines (study period). RESULTS: Overall, 488 of 942 (52%) patients were considered as low risk. Early discharge was achieved in 26 of 230 (11%) patients in the control period and in 191 of 258 (74%) in the study period (P <0.001). Age and number of compensated comorbidities did not affect the rate of early discharge. Length of hospital stay was reduced from (mean +/- SD) 6 +/- 2.7 days (control period) to 3 +/- 2.3 days (study period, P <0.001). No differences were observed in rates of rebleeding, need for surgery, readmission or mortality. By contrast, no differences in lengths of stay were observed during that time period among patients admitted with coronary artery disease, colorectal cancer, or acute pancreatitis. CONCLUSION: Most patients with upper gastrointestinal bleeding who are at low risk for rebleeding can be discharged early, leading to important cost savings.
Adult↗
Impact of antibiotic resistance on chemotherapy for pneumococcal infections.
Over the past three decades, penicillin-resistant pneumococci have emerged worldwide. In addition, penicillin-resistant strains have also decreased susceptibility to other beta-lactams (including cephalosporins) and these strains are often resistant to other antibiotic groups, making the treatment options much more difficult. Nevertheless, the present in vitro definitions of resistance to penicillin and cephalosporins in pneumococci could not be appropriated for all types of pneumococcal infections. Thus, current levels of resistance to penicillin and cephalosporin seem to have little, if any, clinical relevance in nonmeningeal infections (e.g., pneumonia or bacteremia). On the contrary, numerous clinical failures have been reported in patients with pneumococcal meningitis caused by strains with MICs > or = 0.12 microg/ml, and penicillin should never be used in pneumococcal meningitis except when the strain is known to be fully susceptible to this drug. Today, therapy for pneumococcal meningitis should mainly be selected on the basis of susceptibility to cephalosporins, and most patients may currently be treated with high-dose cefotaxime (+/-) vancomycin, depending on the levels of resistance in the patient's geographic area. In this review, we present a practical approach, based on current levels of antibiotic resistance, for treating the most prevalent pneumococcal infections. However, it should be emphasized that the most appropriate antibiotic therapy for infections caused by resistant pneumococci remains controversial, and comparative, randomized studies are urgently needed to clarify the best antibiotic therapy for these infections.
Anti-Bacterial Agents↗
Epidemiology and successful control of a large outbreak due to Klebsiella pneumoniae producing extended-spectrum beta-lactamases.
An outbreak due to extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-KP) was detected from May 1993 to June 1995. A total of 145 patients, particularly patients in intensive care units (ICUs) (107 patients [72%]), were colonized or infected. Infection developed in 92 (63%) patients, and primary bacteremia caused by ESBL-KP was the most frequent infection (40 of 92 patients [43%]). A single clone of ESBL-KP was identified by pulsed-field gel electrophoresis analysis throughout the whole period, and no molecular epidemiological relationship could be found between the epidemic strain and non-ESBL-KP isolates. To determine risk factors for ESBL-KP infection weekly rectal swabs were obtained in three serial incidence surveys (470 patients); the probabilities of carriage of ESBL-KP in the digestive tract were 33% (October and November 1993), 40% (May and June 1994), and 0% (October and November 1995) at 10 days of ICU admission. A logistic regression model identified prior carriage of ESBL-KP in the digestive tract (odds ratio, 3.4; 95% confidence interval 1.1 to 10.4) as an independent variable associated with ESBL-KP infection. A statistically significant correlation was observed between the restricted use of oxyimino-beta-lactams (189 defined daily doses [DDD]/ 1,000 patient-days to 24 DDD/1,000 patient-days) and the trends of ESBL-KP infection (r = 0.7; P = 0.03).
Anti-Bacterial Agents↗
Antibiotic resistance in respiratory pathogens.
Antibiotic resistance in respiratory pathogens has dramatically increased during recent years. Resistance to penicillin and multiple antimicrobial agents in pneumococci and resistance to ampicillin in Moraxella catarrhalis and Haemophilus influenzae, as a result of betalactamase production, have become highly prevalent worldwide. The emergence of multiple drug-resistant tuberculosis in different countries is of concern, and has become a therapeutic challenge.
Drug Resistance, Microbial↗
Staphylococcus aureus nasal carriage as a marker for subsequent staphylococcal infections in intensive care unit patients.
From January to December 1994, 752 consecutive patients admitted to intensive care units (ICU) for more than two days were studied prospectively for Staphylococcus aureus colonization and infection. Nasal swabs were obtained at admission and weekly during the ICU stay. At ICU admission 166 patients (22.1%) were Staphylococcus aureus nasal carriers, while 586 were free of nasal colonization. Of the 166 nasal carriers, 163 harbored methicillin-sensitive Staphylococcus aureus (MSSA) and three methicillin-resistant Staphylococcus aureus (MRSA). During the ICU stay 24 of the 586 noncolonized patients became nasal carriers (11 MSSA and 13 MRSA), and one nasal carrier initially colonized by MSSA was reconlonized by MRSA. Staphylococcal infections were documented in 51 (6.8%) of the total 752 patients. After 14 days of ICU stay, the probability of developing staphylococcal infections was significantly higher for those patients who were nasal carriers at ICU admission than for those found to be initially negative (relative risk 59.6, 95% CI 20.37-184.32; p < 0.0001). In patients with ICU-acquired nasal colonization, most infections were documented prior to or at the time of the detection of the nasal colonization; thus, in this group of patients nasal carriage showed a lower predictive value for subsequent Staphylococcus aureus infections that that described classically. Paired isolates of nasal colonizing and clinical strains were studied by pulsed-field gel electrophoresis (PFGE) and mecA polymorphism analysis in 30 patients; identity was demonstrated in all but two patients. The results suggest that, outside the setting of an outbreak of MRSA, the detection of Staphylococcus aureus nasal carriers on admission may be particularly useful in identifying those patients who are at high risk for developing staphylococcal infections during their ICU stay.
Biomarkers↗
Nosocomial Staphylococcus aureus bacteremia among nasal carriers of methicillin-resistant and methicillin-susceptible strains.
OBJECTIVES: To determine the relevance of nasal carriage of Staphylococcus aureus, either methicillin-sensitive (MSSA) or methicillin-resistant (MRSA), as a risk factor for the development of nosocomial S aureus bacteremia during an MRSA outbreak. PATIENTS AND METHODS: In this prospective cohort study, 488 patients admitted to an intensive care unit (ICU) during a 1-year period were screened with nasal swabs within 48 hours of admission and weekly thereafter in order to identify nasal S aureus carriage. Nasal staphylococcal carriers were observed until development of S aureus bacteremia, ICU discharge, or death. RESULTS: One hundred forty-seven (30.1%) of 488 patients were nasal S aureus carriers; 84 patients (17.2%) harbored methicillin-sensitive S aureus; and 63 patients (12.9%) methicillin-resistant S aureus. Nosocomial S aureus bacteremia was diagnosed in 38 (7.7%) of 488 patients. Rates of bacteremia were 24 (38%) of the MRSA carriers, eight (9.5%) of the MSSA carriers, and six (1.7%) of noncarriers. After adjusting for other predictors of bacteremia by means of a Cox proportional hazard regression model, the relative risk for S aureus bacteremia was 3.9 (95% confidence interval, 1.6-9.8; P = 0.002) for MRSA carriers compared with MSSA carriers. CONCLUSIONS: Among ICU patients, nasal carriers of S aureus are at higher risk for S aureus bacteremia than are noncarriers; in the setting of an MRSA outbreak, colonization by methicillin-resistant strains represents a greater risk than does colonization by MSSA and strongly predicts the occurrence of MRSA bacteremia.
Adult↗
High doses of cefotaxime in treatment of adult meningitis due to Streptococcus pneumoniae with decreased susceptibilities to broad-spectrum cephalosporins.
We treated nine patients (10 episodes) with meningitis caused by Streptococcus pneumoniae isolates with decreased susceptibilities to broad-spectrum cephalosporins with high doses of cefotaxime (300 mg/kg of body weight per day; maximum dose, 24 g/day). Early adjunctive therapy with dexamethasone was also administered. Cefotaxime MICs were 0.5 (three episodes), 1 (five episodes), and 2 (two episodes) micrograms/ml, and MBCs ranged from 1 to 4 micrograms/ml. Therapy was well tolerated, and all patients experienced prompt clinical improvement. One patient died 8 days after the end of therapy, the central nervous system infection had already been cured, and the remaining patients recovered without relapses.
Adult↗
Resistance to penicillin and cephalosporin and mortality from severe pneumococcal pneumonia in Barcelona, Spain.
BACKGROUND: Penicillin-resistant strains of Streptococcus pneumoniae are now found worldwide, and strains with resistance to cephalosporin are being reported. The appropriate antibiotic therapy for pneumococcal pneumonia due to resistant strains remains controversial. METHODS: To examine the effect of resistance to penicillin and cephalosporin on mortality, we conducted a 10-year, prospective study in Barcelona of 504 adults with culture-proved pneumococcal pneumonia. RESULTS: Among the 504 patients, 145 (29 percent) had penicillin-resistant strains of S. pneumoniae (minimal inhibitory concentration [MIC] of penicillin G, 0.12 to 4.0 micrograms per milliliter), and 31 patients (6 percent) had cephalosporin-resistant strains (MIC of ceftriaxone or cefotaxime, 1.0 to 4.0 micrograms per milliliter). Mortality was 38 percent in patients with penicillin-resistant strains, as compared with 24 percent in patients with penicillin-sensitive strains (P = 0.001). However, after the exclusion of patients with polymicrobial pneumonia and adjustment for other predictors of mortality, the odds ratio for mortality in patients with penicillin-resistant strains was 1.0 (95 percent confidence interval, 0.5 to 1.9; P = 0.84). Among patients treated with penicillin G or ampicillin, the mortality was 25 percent in the 24 with penicillin-resistant strains and 19 percent in the 126 with penicillin-sensitive strains (P = 0.51). Among patients treated with ceftriaxone or cefotaxime, the mortality was 22 percent in the 59 with penicillin-resistant strains and 25 percent in the 127 with penicillin-sensitive strains (P = 0.64) The frequency of resistance to cephalosporin increased from 2 percent in 1984-1988 to 9 percent in 1989-1993 (P = 0.002). Mortality was 26 percent in patients with cephalosporin-resistant S. pneumoniae and 28 percent in patients with susceptible organisms (P = 0.89). Among patients treated with ceftriaxone or cefotaxime, mortality was 22 percent in the 18 with cephalosporin-resistant strains and 24 percent in the 168 with cephalosporin-sensitive organisms (P = 0.64). CONCLUSIONS: Current levels of resistance to penicillin and cephalosporin by S. pneumoniae are not associated with increased mortality in patients with pneumococcal pneumonia. Hence, these antibiotics remain the therapy of choice for this disease.
Adult↗
A single daily dose of ceftriaxone for bacterial meningitis in adults: experience with 84 patients and review of the literature.
Although the pharmacokinetics of ceftriaxone allows its administration in a single daily dose, this practice is not standard in the treatment of bacterial meningitis. Herein, we review our experience and that of other investigators with this mode of therapy. We used a single daily dose of ceftriaxone (50 mg/[kg.d]; maximum, 4 g/d) for the treatment of bacterial meningitis in 84 adult patients. Meningitis was due to Neisseria meningitidis in 34 cases, to Streptococcus pneumoniae in 25, to Escherichia coli in three, to Klebsiella pneumoniae in two, to Haemophilus influenzae in two, to viridans streptococci in two, and to an unknown agent in 16. Eleven patients died, for an overall mortality of 13%; therapy failed in three additional cases. The mean trough levels of ceftriaxone in cerebrospinal fluid was 3.5 micrograms/mL; the median trough bactericidal titer at this site was 1:128. Both our experience and that in the literature suggest that a single daily dose is optimal when ceftriaxone is used for the treatment of bacterial meningitis.
Adolescent↗
Characteristics of and risk factors for relapse of brucellosis in humans.
For 16 years we prospectively observed 530 adult patients with brucellosis to analyze the characteristics of and risk factors for relapse. Clinical and laboratory findings from 86 relapsed patients were milder during the relapse episode when compared with those for the same patients during the initial disease. Blood cultures were positive for Brucella melitensis in 65% of cases during relapse and in approximately 80% of cases during the initial disease. Risk factors that were identified as being independently associated with relapse (by logistic regression analysis) were "less-effective" antibiotic therapy (OR, 8.3; 95% CI, 4.6-15.1), positive blood cultures during initial disease (OR, 2.7; 95% CI, 1.2-6.2), < or = 10-day duration of the disease before treatment (OR, 1.9; 95% CI, 1.1-3.6), male sex (OR, 1.8; 95% CI, 1.02-3.8) and a platelet count of < or = 150 x 10(3)/mm3 (OR, 1.7; 95% CI, 1.1-2.8). These data show that relapse of brucellosis is sometimes difficult to diagnose and that it can be an insidious disease. In addition to inappropriate antibiotic therapy, other factors, such as those indicating a more aggressive disease and/or a deficient immunologic response, seem to play an important role in the relapse of brucellosis.
Adolescent↗