the foundation of seimc escmid online lecture library © by
TRANSCRIPT
The foundation of SEIMC
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The Paular Meeting
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My mentors
Prof. José María Segovia de Arana
Prof. Juan Martínez López de Letona
Prof. Manuel Moreno López
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My mentors
Prof. William HewittProf Sidney FinegoldProf Lowell S. YoungProf Colin JordanProf William MartinProf Richard D. MeyerProf Lamar Johnson
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The beginning
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The institutions of my life
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The institutions of my life
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The life-long colleagues
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Part of my team
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The life-long colleagues
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The life-long colleagues
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ESCMID
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Since 1968: Carmen and our family
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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
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Day D: French CoastDay D: French Coast
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PathogenesisPathogenesis
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Pathogenesis
65% 65%
30%30%
Skin and subcut
65% 65%
30%30%
Skin and subcut
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EpidemiologyEpidemiology
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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
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European Data
Bouza E. C.M.I. 2004
ESGNI 5
ESGNI 6Muñoz P. C.M.I. 2004
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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%
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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
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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
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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
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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
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CR-BSI/1000 Ad (p=0.598)
Results
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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
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1.3
Incide
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Years
Adult ICUs Other units
Linear trend Linear trend
p=0.992
p=0.007
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EtiologyEtiology
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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)
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1,255 microorganisms from 1,208 ep CR‐BSI 48 polymicrobial (4%).
3. Evolution of etiology
Gram +67%
Gram ‐17%
Fungi16%
0% CR‐BSI
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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
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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
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03 04 05 06 07 08 09 10Gram negative 1 0.797 1.899 2.211 1.814 2.036 2.821 1.554
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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)
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03 04 05 06 07 08 09 10Fungi 1 0.774 0.698 1.556 1.99 2.114 1.982 1.722
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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)
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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)
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Diagnostic techniques aftercatheter withdrawalDiagnostic techniques aftercatheter withdrawal
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Roll-plate technique (Maki)Roll-plate technique (Maki)
Semiquantitativetechnique
Semiquantitativetechnique
>14 u.f.c./plate
Fina Liñares photographsFina Liñares photographs
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Positivity : 102 ufc
Dx.- Sonication (Sherertz 1990)
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Vortex 1 min1 ml destill. water
Positivity 103 ufc
DX: Quantitative Vortex technique (Brun-Buisson, 1987)
DX: Quantitative Vortex technique (Brun-Buisson, 1987)
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Methods for catheter tip culture
Bouza E. C.I.D. 2005
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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%)
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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
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DX: Gram stain
Impression smear
Randomized trial, Gram stain
Before or after rolling ?
Bouza E. D.M.I.D. 2006
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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%;
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Is all this valid for implantabledevices?Is all this valid for implantabledevices?
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DX: Implantable systemsDX: Implantable systems
Douard MC. C.I.D. 1999
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DX: Implantable systemsDX: Implantable systems
PunchPunch
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Reservoire
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Catheter tip
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Conservative Diagnostictechniques. Conservative Diagnostictechniques.
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High Positive Predictive ValueLow Negative Predictive Value
Dx: Clinical clues: Exit site infectionDx: Clinical clues: Exit site infection
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Are surveillance cultures useful and anticipative?Are surveillance cultures useful and anticipative?
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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
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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)
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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.
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Conservative diagnostic techniques?Conservative diagnostic techniques?
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DX: Comparative quantitative bacteremiaDX: Comparative quantitative bacteremia
≥ 3 timesSpecificity 100%
Sensitivity >80%
Mosca . Surgery 1987Mermel L. C.I.D. 2009
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DX: Differential time to positivityDX: Differential time to positivity
Blot. J.Clin.Microbiol. 1998Mermel L. CID. 2009
≥ 2 hoursFor all microorganisms?
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Raad I. Ann.Intern.Med. 2004
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DTP: In Intensive Care UnitsDTP: In Intensive Care Units
Bouza E. C.I.D. 2007
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DTP: In Intensive Care UnitsDTP: In Intensive Care Units
Bouza E. C.I.D. 2007
DQC:LysisSuperficial DTP
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DTP: In Intensive Care UnitsDTP: In Intensive Care Units
Bouza E. C.I.D. 2007
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
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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
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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
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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%
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Is all of this valid for Candidemia?Is all of this valid for Candidemia?
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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
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Diferential time to positivity
Bouza E. Unpublished information. 2012
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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
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108 episodes of candidemia in adults (84) and children (24)
Our study in Madrid
Bouza E. Unpublished information. 2012
> 30 h > 30 h
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Is the species of Candida of any help?Is the species of Candida of any help?
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C. parapsilosis is more frequently associated to catheter infection and has a better prognosis
Candida parapsilosis
Anaissie E. Am.J.Med. 1998
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Our Experience in HGUGM. Madrid
Bouza E. Unpublished information. 2012
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How to treat?How to treat?
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Systemic +
Lock therapy
Systemic +
Lock therapy
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GlycopeptidesLinezolid
GlycopeptidesLinezolid
++Ceftazidime/Cefepime
Aztreonam
Carbapenems/Pip-Tazo
Tx: Drugs for empirical therapyTx: Drugs for empirical therapy
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-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
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Technique2.3 mL
74% ethanol
20-24 h
Treatment: Antibiotic lock techniqueTreatment: Antibiotic lock technique
Dannenberg C. J.Ped.Hemat.Oncol.2003
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PreventionPrevention
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Pronovost P. N.Engl.J.Med. 2006
The tolerance 0
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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
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4/2/2012 80Ramritu P. Am.J.Infect. Control. 2008
Antibiotic coated catheters.
Non antibiotic coated catheteres vs Antibiotic coated cathetersIntensive Care Units
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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
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4/2/2012 82Lorente L. C.I.D. 2008
8,6/1000
0
Femoral
0
4,93/1000
Yugular
Rifampin-Miconazole Coated catheters
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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
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Ethanol lock prevencion
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
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Ethanol lock prevencion
Non-significant reduction in CR-BSI
Cumbersome and some adverse eventsPérez-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
100 cases
Conventional care
100 cases
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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
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10Commandments10Commandments
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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
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The endThe end
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