The foundation of SEIMC ESCMID Online Lecture Library © by ...

The foundation of SEIMC

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The Paular Meeting

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

My mentors

Prof. José María Segovia de Arana

Prof. Juan Martínez López de Letona

Prof. Manuel Moreno López

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

My mentors

Prof. William HewittProf Sidney FinegoldProf Lowell S. YoungProf Colin JordanProf William MartinProf Richard D. MeyerProf Lamar Johnson

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The beginning

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The institutions of my life

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The life-long colleagues

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Part of my team

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The life-long colleagues

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Since 1968: Carmen and our family

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The Central Venous Catheter, is a link between clinicians and microbiologists

Emilio BouzaHospital Gregorio MarañónUniversity of Madrid. Spain

Emilio BouzaHospital Gregorio MarañónUniversity of Madrid. Spain

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Day D: French CoastDay D: French Coast

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

PathogenesisPathogenesis

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Pathogenesis

65% 65%

30%30%

Skin and subcut

65% 65%

30%30%

Skin and subcut

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

EpidemiologyEpidemiology

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

US Data

Mermel L. C.I.D. 2009

150.000.000 devices

20,000,000 with I.V. therapy

5,000,000 central v. cath.

250,000 catheter's infections

120,000 bloodstream infections

Extra cost/case

Mean stay 7 - 21 days

8.000 to 40.000 $ more

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

European Data

Bouza E. C.M.I. 2004

ESGNI 5

ESGNI 6Muñoz P. C.M.I. 2004

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

European Data

Bouza E. C.M.I. 2004

ESGNI 5 and 6

Muñoz P. C.M.I. 2004

ICU38%

Medical27%

Other7%

Surgical26%

Pediatrics (non ICU)

2%

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Epidemiology

Attributable mortality 12-25%Attributable mortality 12-25%

Prolongation of hospitalization 10-40 dProlongation of hospitalization 10-40 d

Extra cost 8,000 to 40,000 $ episodeExtra cost 8,000 to 40,000 $ episode

Pittet D. JAMA 1994; Smith RL. Chest 1991

Pittet D. JAMA 1994; Digiovine B. A.J.R.C.C.M. 1999

Mermel LA. Ann.Intern.Med. 2002; Arnow PM. C.I.D. 1993

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Evolution and etiologic shift of catheter‐related bloodstream infection in a whole institution. Can the microbiology department act as a watchtower?

Marta Rodríguez‐Créixems1,2,3, MD Patricia Muñoz1,2,3, MD Pablo Martín‐Rabadán 1, MDEmilia Cercenado1,2,3, Pharm DMaría Guembe1, PharmDEmilio Bouza1,2,3, MD

23

16:48 ‐ 17:00 Bacteraemia and surgical site infections (Platinum Suite 3/4)

Monday, April 02, 2012

1 Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Department of Medicine. Facultad de Medicina. Universidad Complutense, Madrid, Spain2 CIBER de Enfermedades Respiratorias (CIBERES CD06/06/0058), Palma de Mallorca, Spain. 3 Red Española para la investigación en Patología Infecciosa (REIPI), RD06/0008/1025

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Evolution of CR‐BSI 479,710 admissions (mean, 59,964 admissions/year)

Significant BSI: 14,713 (30.67 episodes/1,000 ad) 1,208 episodes (8.2%) CR‐BSI

‐ 1.9 to 3.6 episodes/1,000 ad (mean, 2.5 ep/ ad)

10.918

0.985

1.11.193 1.177 1.207

1.018

0.2

0.4

0.6

0.8

1

1.2

1.4

2003 2004 2005 2006 2007 2008 2009 2010

Inci

denc

e R

ate

Rat

io

Years

CR-BSI/1000 Ad (p=0.598)

Results

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Evolution of incidence rate ratio of the CR‐BSI/1000 admissions in adult ICUs compared with the remaining hospital units

2003 2004 2005 2006 2007 2008 2009 2010Adult ICUs 1 0.749 0.743 0.9 0'001 0.652 0.877 0.548Other units 1 0'001 0.907 0.692 0.925 0'001 1.337 0'001

0.3

0.5

0.7

0.9

1.1

1.3

Incide

nce Ra

te Ratio

Years

Adult ICUs Other units

Linear trend Linear trend

p=0.992

p=0.007

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

EtiologyEtiology

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Etiologic shift

A shift in the etiologic spectrum of CRBSI may be in

progress, with a gradual decrease in Gram-positive

CRBSI and significant increases in Gram-negative

and Candida infections

Rodríguez-Créixems M. ECCMID 2012

Evolution and aetiologic shift of catheter‐related bloodstream

infections. Should the microbiology department be a watchtower for a

whole institution?

M. Rodríguez‐Creixems*, M. Guembe, P. Muñoz, P. Martín‐Rabadán, E.

Cercenado, E. Bouza (Madrid, ES)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

1,255 microorganisms from 1,208 ep CR‐BSI 48 polymicrobial (4%).

3. Evolution of etiology

Gram +67%

Gram ‐17%

Fungi16%

0% CR‐BSI

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Evolution of CRBSI etiology: Gram +ves

03 04 05 06 07 08 09 10Gram positive 1 0.693 0.81 0.674 0.768 0.839 1.208 0.751#REF! 1#REF! 1

0

0.5

1

1.5

2

2.5

3

3.5

4

Inci

denc

e R

ate

Rat

io

Year

Gram +(831 ep): 25% reduction (95% CI, 1‐44%; p=0.04)

S. aureus from 0.82 to 0.33 /1000 adm (9%/annual decrease; p=0.006)

Enterococcus spp. from 0.09 to 0.22 /1000 adm (19% annual increase; p=0.001).

CNS stable

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

03 04 05 06 07 08 09 10Gram negative 1 0.797 1.899 2.211 1.814 2.036 2.821 1.554

0

0.5

1

1.5

2

2.5

3

3.5

4

Inci

denc

e R

ate

Rat

io

Year

Evolution of CRBSI etiology: Gram ‐ves

Gram ‐ (209 episodes): 8.9% increase (95% CI, 2.6‐15.7%; p=0.005)

Klebsiella spp., Enterobacter spp., Escherichia coli, Serratiaspp., and a miscellany of other bacteria in decreasing order

Pseudomonas aeruginosa: 14% annual increase(p=0.090)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

03 04 05 06 07 08 09 10Fungi 1 0.774 0.698 1.556 1.99 2.114 1.982 1.722

0

0.5

1

1.5

2

2.5

3

3.5

4

Inci

denc

e R

ate

Rat

io

Year

Evolution of CRBSI etiology

C. albicans: 24% annual increase (95% CI, 11‐38%; p<0.001)

The rest stable

Fungus: 14% increase (95% CI, 6‐21%; p<0.001)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Gram negatives

17% of all CR-BSI

GN-CRBSI were more common in non

immunosuppressed, underlying neurologic conditions,

previous antimicrobial therapy, non–subclavian

insertion site, and rapid blood cultures growing (< 8

hours).Eworo A. ECCMID 2012

Case‐control analysis of Gram‐negative catheter‐related bloodstream

infection in a tertiary care medical centre

A. Eworo, P. Muñoz*, M. Rodríguez‐Creixems, A. Fernandez‐Cruz, E.

Reigadas, E. Bouza (Madrid, ES)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Diagnostic techniques aftercatheter withdrawalDiagnostic techniques aftercatheter withdrawal

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Roll-plate technique (Maki)Roll-plate technique (Maki)

Semiquantitativetechnique

Semiquantitativetechnique

>14 u.f.c./plate

Fina Liñares photographsFina Liñares photographs

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Positivity : 102 ufc

Dx.- Sonication (Sherertz 1990)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Vortex 1 min1 ml destill. water

Positivity 103 ufc

DX: Quantitative Vortex technique (Brun-Buisson, 1987)

DX: Quantitative Vortex technique (Brun-Buisson, 1987)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Methods for catheter tip culture

Bouza E. C.I.D. 2005

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DX: Long-term tunneled catheters

Prospective study, 149 tunneled catheters

Colonized (26.2%). Causing CRBSI 11 (7.4%)

Guembe M, Bouza E. J.Clin.Microbiol. 2012

Roll-plate method (95%)

Sonication (44%)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DX: Long-term tunneled catheters

Gram stain of the tip in the prediction of

Colonization or CRBSI

Guembe M, Bouza E. J.Clin.Microbiol. 2012

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DX: Gram stain

Impression smear

Randomized trial, Gram stain

Before or after rolling ?

Bouza E. D.M.I.D. 2006

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DX: Gram stain

Bouza E. D.M.I.D. 2006

Author. Year

Study Sen % Spe% PPV% NPV%

Cooper1985NEJM

Cath tips 100 97 84 100

Collignon1987Arch I M

Cath tips 83 81 44 96

Aygun2006DMID

Cath tips 100 95 70 100

Bouza2006DMID

Before CAfter C

94.3%69.6%;

92.4%96.2%

80.6%86.7%;

98.0%/90.0%;

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Is all this valid for implantabledevices?Is all this valid for implantabledevices?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DX: Implantable systemsDX: Implantable systems

Douard MC. C.I.D. 1999

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DX: Implantable systemsDX: Implantable systems

PunchPunch

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Reservoire

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Catheter tip

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Conservative Diagnostictechniques. Conservative Diagnostictechniques.

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

High Positive Predictive ValueLow Negative Predictive Value

Dx: Clinical clues: Exit site infectionDx: Clinical clues: Exit site infection

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Are surveillance cultures useful and anticipative?Are surveillance cultures useful and anticipative?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

4/2/2012 51Bouza E. Crit.Care Med. 2005

Dx. Surveillance of superficial cultures

A prospective cohort study11 bed ICU for Major Heart Surgery130 patients, 561 catheters3,712 cultures taken

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Prediction of superficial cultures for CR-BSIPrediction of superficial cultures for CR-BSI

Sensitivity 100% (74.7-100)

Specificity 64.7% (60.5-68.6)

PPV 7.2% (4.2-11.8)

NPV 100% (98.7-100)

PLR 2.83 (2.83-2.83)

NLR 0 (0.10-0.10)

Accuracy 65.6% (65.5-65.7)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Predictive Value of Superficial Cultures to Anticipate Tunneled Hemodialysis Catheter-Related Bloodstream Infections. “COCADI”

Department of Nephrology

Department of Clinical Microbiology and Infectious Diseases

Surveillance superficial cultures (skin and hubs)

Patients with an hemodialysis tunneled catheter

HIGH PREVALENCE OF CATHETER USE.

INCIDENCE CRBSI RATE: 0,35 EPISODES / 1,000 CATHETER DAYS.

HIGH PREVALENCE OF SKIN COLONIZATION (64.3%).

NONE OF UN-COLONIZED POPULATION DEVELOPED INFECTION (SENSITIVITY AND NPV 100%).

COLONIZED POPULATION PREVENTIVE MEASURES.

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Conservative diagnostic techniques?Conservative diagnostic techniques?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DX: Comparative quantitative bacteremiaDX: Comparative quantitative bacteremia

≥ 3 timesSpecificity 100%

Sensitivity >80%

Mosca . Surgery 1987Mermel L. C.I.D. 2009

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DX: Differential time to positivityDX: Differential time to positivity

Blot. J.Clin.Microbiol. 1998Mermel L. CID. 2009

≥ 2 hoursFor all microorganisms?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Raad I. Ann.Intern.Med. 2004

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

DTP: In Intensive Care UnitsDTP: In Intensive Care Units


ESCMID O

nline

Lectu

re Lib

rary

© by au

thor



DQC:LysisSuperficial DTP

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor



Superficial DQC DTTP

Sensitivity 78.6 71.4 96.4

Specificity 92.0 97.7 90.3

PPV 61.1 83.3 61.4

NPV 96.4 95.6 99.4

Accuracy 90.2 94.1 91.2

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

IDSA Guidelines-2009: Blood culturesIDSA Guidelines-2009: Blood cultures

16It is not clear how many lumens of the catheter must be cultured to do differential blood cultures

C-

III

Mermel L. C.I.D. 2009

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

4/2/2012 62Guembe M. Bouza E. C.I.D. In press

Number of lumens to culture

How Many Lumens Should Be Cultured inthe Conservative Diagnosis of Catheter-Related Bloodstream Infections?

How Many Lumens Should Be Cultured inthe Conservative Diagnosis of Catheter-Related Bloodstream Infections?

Multilumen catheters with confirmed CR-BSIBlood obtained by all lumensMissed episodes if blood had not been

cultured from 1 or 2 lumens

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

4/2/2012 63Guembe M. Bouza E. C.I.D. 2011

Episodes diagnosed according to blood taken from different lumens

Double-Lumen (112)

Triple lumen (59)

Culturing 1 lumen

72.8% 62.7%

Culturing 2 lumens

100% 84.2%

Culturing 3lumens

100%

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Is all of this valid for Candidemia?Is all of this valid for Candidemia?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Median time to positivity in Candidemia blood cultures (hours)Median time to positivity in Candidemia blood cultures (hours)

0 20 40 60 80

C krusei

C. tropicalis

C. parapsilosis

C. albicans

C. glabrata

Bouza E. Unpublished information. 2012

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Time to positivity< 30 hSensitive but non-specific> 30 h Rule out Catheter origin

Time to positivity and candidemia

Ben-Ami R. J.Clin.Microb. 2008

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

108 episodes of candidemia in adults (84) and children (24)

Our study in Madrid


> 30 h > 30 h

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Is the species of Candida of any help?Is the species of Candida of any help?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

C. parapsilosis is more frequently associated to catheter infection and has a better prognosis

Candida parapsilosis

Anaissie E. Am.J.Med. 1998

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

GlycopeptidesLinezolid

GlycopeptidesLinezolid

++Ceftazidime/Cefepime

Aztreonam

Carbapenems/Pip-Tazo

Tx: Drugs for empirical therapyTx: Drugs for empirical therapy

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

-Taurolidine

-Derivative of Tauronimide

-Antiseptic developed in the 60’s

-Active against Gram + and Gram –

-Antifungal activity

-Available as a 2% solution

-Non toxic. Metabolized to taurine+CO2+H2O

-Can be administered intraperitoneally and IV

-Taurolidine

-Derivative of Tauronimide

-Antiseptic developed in the 60’s

-Active against Gram + and Gram –

-Antifungal activity

-Available as a 2% solution

-Non toxic. Metabolized to taurine+CO2+H2O

-Can be administered intraperitoneally and IV

Treatment: TaurolidineTreatment: Taurolidine

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Technique2.3 mL

74% ethanol

20-24 h

Treatment: Antibiotic lock techniqueTreatment: Antibiotic lock technique

Dannenberg C. J.Ped.Hemat.Oncol.2003

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

4/2/2012 79Labeau SO. Crit.Care.Med. 2009

Knowledge of European nurses

¿What European ICU nurses know about preventive measures of CRI’s?

26 countries, 3405 questionnaires

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

4/2/2012 80Ramritu P. Am.J.Infect. Control. 2008

Antibiotic coated catheters.

Non antibiotic coated catheteres vs Antibiotic coated cathetersIntensive Care Units

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

4/2/2012 81Lorente L. C.I.D. 2008

Rifampin-Miconazole Coated catheters

ICU. Femoral catheters (184)

73 Rifa-Miconazole/115 standardYugular Catheters (241)

114 Rifa-Miconazole/127 standard

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

4/2/2012 82Lorente L. C.I.D. 2008

8,6/1000

0

Femoral

0

4,93/1000

Yugular

Rifampin-Miconazole Coated catheters

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Ethanol lock prevencion

Academic, prospective, randomized, clinical trial

Intensive Care Unit post Major Heart Surgery

Prevention of CR-BSI, Tolerance

Pérez-Granda M. ECCMID 2012

Ethanol lock therapy in the prevention of catheter‐related bloodstream

infections after major heart surgery

M.J. Pérez, J.M. Barrio*, C. Rincón, J. Hortal, P. Martín‐Rabadán, S.

Pernia, E. Bouza (Madrid, ES)

Ethanol Locks

every 3 days

Conventional care

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor


Prospective randomized, clinical trial

Intensive Care Unit post Major Heart Surgery

Prevention of CR-BSI, Tolerance

Pérez-Granda M. ECCMID 2012





Ethanol Locks

every 3 days

Conventional care

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor


Non-significant reduction in CR-BSI

Cumbersome and some adverse eventsPérez-Granda M. ECCMID 2012





Ethanol Locks

every 3 days

100 cases

Conventional care

100 cases

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The future

Better definitions of CR-BSI. Genotypic identity

Better diagnostic techniques: Molecular biology

Better catheter materials

Better antibiotic treatments with catheter

preservation

Better prevention and zero tolerance to infection

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

1.- ESCMID executive

2.- Award Committee

3.- Founding Members of the SEIMC

4.- My mentors

5.- My long term and short term colleagues

6.- The Spanish Microbiologists and ID clinicians

7.- The old members of my team

8.- The young members of my team

9.- My very generous friends

10.- My family and grandson

1.- ESCMID executive

2.- Award Committee

3.- Founding Members of the SEIMC

4.- My mentors

5.- My long term and short term colleagues

6.- The Spanish Microbiologists and ID clinicians

7.- The old members of my team

8.- The young members of my team

9.- My very generous friends

10.- My family and grandson

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The foundation of SEIMC ESCMID Online Lecture Library © by ...

Documents

Transcript of The foundation of SEIMC ESCMID Online Lecture Library © by ...