María Inés Staneloni

We sincerely thank you for your thoughtful letter (1) and for the interest you have shown in our study. This kind of scholarly exchange is precisely what advances our collective understanding of such a complex and pressing issue, and we are truly grateful for it.

Background/Objectives: Data on multidrug-resistant organism (MDRO) infections in children are scarce, especially in resource-limited regions. This study aimed to estimate the prevalence of MDRO infections in pediatric intensive care units (PICUs) and characterize their epidemiologic and clinical features. Methods: A national, multicenter, point-prevalence study was conducted in 50 PICUs in Argentina over 24 h between 24 and 28 November 2023. The primary study outcome was the prevalence of ICU infections caused by MDROs. Secondary outcomes included the prevalence of carbapenemase-producing Enterobacterales (CPE) colonization, ICU mortality, and ICU length of stay (LOS_ICU). Results: 304 patients were included. The overall prevalence of infection was 45.1% (137/304); of these, 50.3% (69/137) were hospital-acquired. Among the 137 patients with reported infections, 49.6% (n = 68) were classified as definite (microbiologically confirmed) and 50.4% (n = 69) as probable (no confirmatory microbiology). Among definite infections, 20.6% (n = 14) were due to MDROs. The overall prevalence of MDRO infections was 4.6% (14/304). Extended-spectrum β-lactamase (ESBL)-producing organisms were the most commonly identified microorganisms (42.9%), followed by CPE (28.6%). Ventilator-associated pneumonia (VAP) was the most frequent location of MDRO infections. The prevalence of CPE colonization was 13.2%. Mortality was low (5.3%) and similar in patients with MDRO and non-MDRO infections. LOS_ICU was longer in patients with MDRO infections compared to patients with non-MDRO infections (81 [22–150] vs. 25 [12–27] days, respectively, p = 0.0007). Conclusions: Among 304 PICU patients, the prevalence of MDRO infections and colonization was relatively low. MDRO infections were not associated with increased mortality but were associated with longer ICU stays, compared to patients with non-MDRO infections.

Data from low and middle-income countries (LMICs) on multidrug-resistant microorganisms (MDROs) in intensive care units (ICUs) are scarce. Working in several ICUs in Argentina, we sought to estimate the prevalence and characteristics of MDRO infections and carbapenemase-producing Enterobacterales (CPE) colonization. Mortality associated with MDRO infection was also evaluated. The study was a 24-hour point prevalence study conducted in 164 adult ICUs in Argentina between 24 November and 28 November 2023. The main study outcome was in-ICU mortality and secondary outcomes included the prevalence of MDRO infections, the prevalence of CPE colonization (defined as CPE recovered from a rectal swab), and ICU length of stay (LoS). Mixed effects modeling was used to identify risk factors for in-ICU mortality. Among 1,799 patients, 933 (51.9%) had a reported infection; 599 infections (64.2%) were classified as definite (i.e., with positive cultures) and 334 (35.8%) as probable infection (i.e., negative cultures but signs of infection). Of the 933 patients with infection, 273 (29.2%) had an MDRO recovered with 344 total MDRO cultures recovered. Non-MDRO was recovered from 326 (34.9%) of the 933 patients. Among definite infections, 45.5% (273/599) were due to MDRO with an overall prevalence of MDRO of 15.1% (273 patients with MDRO infections/1,799 patients). CPE colonization, defined as a positive rectal swab taken during the incident hospitalization, occurred in 420/1,696 (24.7%) patients. The most frequent MDRO infection was ventilator-associated pneumonia (100/344; 29.1%). The most common MDRO recovered were carbapenem-resistant Acinetobacter baumannii and CPE (98/344, 28.5% each). In-ICU mortality was 27.1% (487/1,799); independent predictors were age (odds ratio [OR] 1.01 [1.00–1.02], P = 0.003), MDRO infection (OR 1.65 [1.18–2.43], P = 0.012), probable infection (OR 1.41 [0.97–2.04], P = 0.073), sepsis-related organ failure assessment (SOFA) score (OR 1.18 [1.13–1.23], P = 0.000), and hospital-acquired pneumonia (OR 1.84 [1.12–3.01], P = 0.016). Mortality also varied significantly by hospital ( P < 0.001). LoS was significantly longer in patients with MDRO infections, 30.0 (interquartile range [IQR] 17–35) days vs 16.0 (IQR 8–33) in non-MDRO, P < 0.0001. Among 1,799 ICU patients in an LMIC, the prevalence of MDRO infection and CPE colonization was high. The presence of an MDRO infection was associated with increased mortality and prolonged ICU LoS. CLINICAL TRIALS: This study is registered with Clinicaltrials.gov as NCT06574776 .

The extended use of broad-spectrum antimicrobials contribute to the growing threat of antimicrobial resistance. This study evaluated the impact of a multimodal strategy aiming at reducing the duration of broad-spectrum antimicrobial therapy in Ventilator-Associated Pneumonia (VAP). Conducted in a single Intensive Care Unit (ICU), this quasi-experimental, retrospective study compares a pre-intervention period (08/01/2018-07/01/2019) with an intervention period (08/01/2022-07/01/2023). Adult patients receiving antimicrobials for suspected VAP with positive respiratory cultures were included, 35 and 53 VAP events in the pre-intervention and intervention period, respectively. The intervention combined a diagnostic and treatment algorithm with a multiplex PCR Pneumonia Panel (PnP), education for the ICU staff, and enhanced communication with a multidisciplinary consultation group. The median time from antibiotic prescription to modification decreased from 76 h (IQR 63-100) to 21 h (IQR 8-31), a reduction of 55 h (95% CI -67, -42; p<0.001). The time difference for each of the most used broad spectrum antimicrobials, vancomycin, carbapenems and colistin, was not statistically significant (-28 h [95% CI-64, 8; p = 0.129], -3.4 h [95% CI -51 , 44; p = 0.888] and -25 h [95% CI-56, 5; p = 0.104] respectively).The PnP demonstrated high specificity (100% [95%CI 92.3-100]) and negative predictive value (98.2%) for methicillin-resistant Staphylococcus aureus with a sensitivity of 83.3% (95% CI35.9-99.6), and moderate performance for extended-spectrum beta-lactamase detection with a sensitivity of 62.5% (95% CI 24.5-91.5), specificity of 84.1% (95% CI 69.9 - 93.4) and negative predictive value of 88.2%. This study demonstrates that a multimodal strategy with a rapid diagnostic method, education and improved communication can significantly reduce the duration of empirical broad-spectrum antimicrobials in critical patients treated for VAP.

Se estima que aproximadamente uno a tres de cada mil pacientes sometidos a cirugía sufrirá una infección vinculada con el procedimiento (1). Incluso, probablemente esa cifra sea aun mayor en los en los países en desarrollo. De más está decir que esto se asocia con un elevado impacto en vidas humanas y en gastos relacionados. Numerosas publicaciones indican que la adecuada instrumentación de un conjunto de medi- das preventivas es una herramienta útil para intentar evitar o disminuir el desarrollo de infec- ciones asociadas al acto quirúrgico (2). La correcta profilaxis antibiótica prequirúrgica es uno de los pilares para la prevención de infecciones del sitio quirúrgico (ISQ). Su finalidad es impedir la aparición de ISQ a través de lograr alcanzar los niveles de concentración óptima de los antibióticos en sangre y tejidos, para evitar la proliferación y diseminación bacteriana. Para ello es preciso contar con datos actualizados de la microbiología local a fin de adecuar los tratamientos a la situación epidemiológica y con protocolos que permitan una adecuada administración de los antibióticos en tiempo y forma, así como un correcto seguimiento de todo el proceso. Con ese objetivo, la Sociedad Argentina de Infectología convocó a la Asociación Argentina de Cirugía y a la Asociación de Anestesia, Analgesia y Reanimación de Buenos Aires para tra- bajar de manera consensuada en la actualización de las recomendaciones emitidas en 2017 (3), con una visión que permita un enfoque multidisciplinario. Creemos que este documento será de gran utilidad para todos los agentes involucrados en el manejo de pacientes quirúrgicos, así como una herramienta fundamental para el control de las infecciones asociadas al cuidado de la salud.

Estudio cuasi-experimental desarrollado para disminuir el impacto de la resistencia a los antimicrobianos a través de un programa de prevención de infecciones y optimización del uso de antimicrobianos construido “a medida” según las posibilidades de la institución. Se implementó: vigilancia de colonización e infección por enterobacterias productoras de carbapenemasas (EPC); vigilancia y medidas preventivas para infecciones urinarias asociadas a sonda vesical (ITU); vigilancia e intervenciones para mejorar la higiene de manos; guías locales de tratamiento de enfermedades infecciosas con evaluación de adherencia a las mismas y consumo de antibióticos (ATB). Resultados: comparando periodo pre y postintervención: tasa de EPC en muestras clínicas: 1,1 a 0/días paciente; razón de tasas de incidencia (IRR: 0.00, p: 0.033); tasa de colonización: 3,3 a 0,61/días paciente (IRR: 0.18, p: 0.5). Tasa de ITU 8,9 a 7,2/1000 días catéter urinario (IRR: 0.81, p 0.5). Adherencia a higiene de manos: 77,5% a 70,38% (p 0.0067). Consumo de ATB: 376,24 a 176,82 DDD, (disminución 53%). Adherencia a guías en elección de ATB: 57,1% a 95,4% (p 0.00031); duración de ATB: 92,8% a 98,4% (p 0.16); adecuación según rescate microbiológico:57,1% a 100% (p <0.01). Conclusión: un programa con medidas simples, a medida, con supervisión externa, redujo en un tiempo relativamente corto las infecciones por EPC, el consumo y uso apropiado de ATB en un hospital público de medianos/bajos recursos.

Objetivo: Evaluar prevalencia y adecuación de ceftriaxona tras una intervención educativa en un servicio de urgencias. Métodos: Estudio cuasi experimental que incluyó un mues- treo consecutivo de consultas no programadas de pacien- tes adultos, durante dos meses preintervención y posin- tervención. Dicha intervención consistió en capacitación a médicos para limitar su indicación sólo a situaciones clínicas específicas (meningitis, enfermedad pélvica infla- matoria y abdomen agudo). Se utilizaron datos retrospecti- vos, con adicional revisión manual de historias, para validar adecuación de inicio antibiótico y apropiabilidad de droga. Se utilizó estadística descriptiva y analítica. Resultados: De un total de 28.570 consultas, 512 recibie- ron ceftriaxona (1,79%; IC95% 1,64-1,95), y sólo 60,54% se hospitalizaron. En cuanto a la comparación antes-después, se observó una reducción en la tasa de uso (de 3,66% a 0,63%; p<0,001), la adecuación en el inicio de un antimicro- biano se mantuvo (de 84,52% a 86,21%; p=0,778), aunque la adecuación de ceftriaxona aumentó en forma significativa (de 41,78% a 84,00% respectivamente; p<0,001). Adicional- mente, se redujo el tiempo de estadía hospitalaria (media- na de 6 a 5 días; p=0,014), sin diferencias en la mortalidad intrahospitalaria (19,44% vs 17,24%; p=0,691), ni en la mor- talidad a los 30 días (23,41% vs 18,96%; p=0,464). Conclusiones: Esta intervención resultó eficaz. Los hallaz- gos representan un paso fundamental en los programas de optimización del uso de antimicrobianos hospitalarios, que apuntan a reducir su sobreutilización y la consecuente resistencia.

Introduction: The problem of carbapenemase-producing Enterobacteriaceae (CPE) was exacerbated by the COVID-19 pandemic in countries with a previous high incidence, such as Argentina. This study describes the development and results of a CPE prevention program, mainly carbapenemase-producing Klebsiellas (KPC), in three critical units of two public hospitals during 6 months of the pandemic. Methods: The objective was to reduce the incidence of KPC in clinical and colonization samples. This quasi-experimental study was based on a cycle of improvement and implementation of three measures: hand hygiene, environmental hygiene, and periodic surveillance with rectal swabs. Results: Regarding the measures, all the units optimized active surveillance, and two of these also improved hand and environmental hygiene. Comparing the pre-and post-intervention periods in the three units, no significant change was observed in the rate of KPC positive clinical samples. KPC coloni-zation was significantly reduced in two units (unit 2: 51.6-18.5 p 0.0004, unit 3: 62.5-5.2 p < 0.0000001). All units showed a downtrend in both rates towards the end of the study. Conclusion: Containing or reducing the advance of the KPC in our region is possible even in difficult scenarios such as the pandemic. More studies are needed in low-and middle-income countries to demonstrate the impact of KPC prevention programs in these situations.

Introduction: It has been proposed that exposure to pulmonary function tests (PFT) could be associated with a higher risk of viral transmission. The risk of the Coronavirus Disease 2019 (COVID-19) transmission after performing PFT is unknown. We aimed to assess the incidence of COVID-19 after a PFT at an academic teaching facility in Buenos Aires, Argentina. Materials and methods: We conducted a retrospective cohort study including all consecutive adult patients that performed PFT between April 1, 2020 and September 30, 2020. Patients with prior COVID-19 were excluded. We defined a 15-day time window to ascertain PFT related COVID-19. The primary outcome was ascertained by consulting a national database, which has information on all patients with nasopharyngeal swabs for SARS-CoV-2 in Argentina. Results: We included 278 patients who performed a PFT. Fifty percent were women, the mean age was 54 years (SD 18), and the main comorbidities were obesity (31%), smoking (31%), hypertension (29%), and chronic lung disease (28%). The main indication for performing PFT was anesthetic preoperative risk assessment. Swabs were collected from 27 patients (10%). Twenty-two swabs (8%) were taken according to surgical protocols; five swabs (2%) were taken due to clinical suspicion of COVID-19, with only one testing positive. The cumulative incidence of COVID-19 after PFT was 0.36% (95% CI 0.01-20%). None of the technicians developed symptomatic disease. Conclusion: Given the right setting and strict adherence to international recommendations, the SARS-CoV-2 infection after having a PFT appears to be low, which follows that these procedures can be performed safely for both patients and staff.